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Job Description:
Purpose of Position
The Medicare Quality & Risk Adjustment Program Lead/RN is responsible for operational leadership and coordination of Medicare Advantage Quality, HEDIS, Stars, Risk Adjustment, and audit readiness activities. Serves as the primary subject matter expert and operational lead for HEDIS reporting, supplemental data collection, vendor management, provider reporting, risk adjustment program execution, chart retrieval activities, RADV readiness, and performance improvement initiatives. Partners with internal stakeholders, provider organizations, consultants, and vendors to ensure accurate reporting, regulatory compliance, and achievement of organizational quality and risk adjustment goals
Essential Job Functions
Quality, HEDIS & Stars
- Coordinate annual HEDIS reporting activities and NCQA audit preparation.
- Serve as primary liaison with HEDIS auditors and external quality vendors.
- Maintain HEDIS Roadmap documentation, audit tracking tools, and compliance requirements.
- Oversee monthly HEDIS data refresh processes, validation activities, and supplemental data collection.
- Manage HEDIS vendor applications and related workflows.
- Monitor HEDIS and Stars performance trends and identify opportunities for improvement.
- Produce and distribute quality performance reports, gap lists, and leadership reporting.
- Support Stars measure owners with performance monitoring, strategy implementation, and gap closure activities.
- Coordinate quality improvement campaigns and member outreach initiatives.
- Evaluate and implement new data sources that improve HEDIS reporting accuracy and digital quality measurement capabilities.
Risk Adjustment & RADV
- Serve as operational lead for Risk Adjustment program activities and vendor coordination.
- Manage RA Vendor platform administration, project configuration, user access, and workflow oversight.
- Coordinate prospective and retrospective risk adjustment initiatives, including chase creation and project management.
- Oversee chart retrieval operations, medical record collection, and provider outreach activities.
- Coordinate coding sweep projects, chart packaging, coding vendor activities, and project timelines.
- Monitor Clinical Intelligence outputs, suspect identification performance, and tuning opportunities.
- Support monthly roster loads, report generation, and integration of risk adjustment data into provider reporting processes.
- Coordinate RADV readiness activities, including chase creation, medical record retrieval, documentation management, and audit response support.
- Monitor operational metrics including retrieval rates, coding completion, suspect conversion, chart completion, and project turnaround times.
- Collaborate with consulting partners and coding vendors to identify process improvements and maximize program effectiveness.
- Conduct hands-on medical record abstraction and clinical data extraction from provider EHRs to support risk adjustment data validation, coding, and RADV audits.
Provider Reporting & Analytics
- Coordinate production and distribution of provider gap closure reports and performance reporting.
- Ensure integration of HEDIS, Stars, and Risk Adjustment data into provider-facing reporting.
- Validate report accuracy and support provider engagement activities.
- Partner with Business Intelligence teams to maintain data integrity and reporting consistency.
Vendor & Program Management
- Serve as primary operational contact for quality and risk adjustment vendors.
- Coordinate project timelines, deliverables, issue resolution, and performance monitoring.
- Maintain SOPs, workflows, training materials, and process documentation.
- Support implementation of new programs, technologies, and reporting enhancements.
- Ensure compliance with CMS, NCQA, and organizational requirements.
Experience
Minimum Required
- 2 + years of health plan experience specifically in Medicare Advantage Quality, HEDIS, Stars or Risk Adjustment operations.
- 3+ years of clinical practice experience in acute, ambulatory or managed care setting.
- Demonstrated experience supporting HEDIS reporting, performance monitoring, and quality improvement initiatives.
- Experience working with risk adjustment workflows, chart retrieval, coding vendor coordination, or HCC documentation processes.
- Familiarity with CMS Medicare Advantage regulations, NCQA HEDIS audit proceses, and RADV requirements.
Preferred
- 3–5 years of experience in Medicare Advantage quality performance, Stars improvement, or risk adjustment program execution.
- Experience supporting or leading cross-functional initiatives involving Quality, Member Experience, Risk Adjustment, Compliance, and Provider Engagement.
- Experience with project management, workflow optimization, or vendor oversight in a health plan environment.
- Experience working with population health, value-based care programs, or provider performance reporting.
Certifications/Licenses
- Active, unrestricted Registered Nurse License
- Bachelor’s degree in Nursing, Healthcare Administration, Public Health or related field
Knowledge & Skills
- Strong working knowledge of HEDIS measures, Stars methodology, CAHPS drivers, and CMS quality programs.
- Understanding of risk adjustment models (HCC/RAF), prospective and retrospective coding workflows, and RADV audit processes.
- Ability to interpret and validate clinical, claims, and supplemental data to support accurate reporting and performance improvement.
- Proficiency with quality and risk adjustment vendor platforms, chart retrieval systems, and provider reporting tools.
- Strong analytical skills with the ability to identify trends, validate data, and translate insights into operational action.
- Excellent communication and relationship‑building skills with providers, vendors, and internal stakeholders.
- Ability to manage multiple projects, timelines, and deliverables in a fast‑paced regulatory environment.
- Demonstrated ability to support a culture of continuous improvement, accountability, and member‑centric service.
Certifications
Preferred
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Risk Adjustment Coder (CRC) or equivalent
Equal Opportunity Employer
Salary: $128,876 annually
Assigned Work Hours:
Full time (exempt) 8am-5pm PST
Position Type:
RegularOriginally posted on