Responsibilities & Qualifications

PURPOSE: Provides overall strategic, administrative and operations management of Stars and Risk Adjustment for Medical Affairs related to Medicare and Medicaid books of business.  Oversees and coordinates the development and implementation of all programs aimed at improved performance and member health for Medicare and Medicaid populations.  Acts as internal expert in pursuit of maximum 5.0 Star Rating and to optimize risk-adjusted revenue, integrating risk-adjustment and Star improvement activities with member’s healthcare.  Enables a stable risk adjustment system to ensure sustainability in benefits provided to enrollees and to the continued innovation in the delivery of high quality, coordinated and affordable care to Medicare beneficiaries. Coordinate interdepartmental programs and allocates, prioritizes and plans the use of human and financial resources.

PRINCIPAL ACCOUNTABILITIES:

Under the general direction of the Executive Vice President Medical Affairs the incumbent’s responsibilities include, but are not limited to, providing strategic direction, leadership, and oversight as follows:

Direct enterprise strategic and operational efforts to optimize risk adjusted revenue and earn ality bonus payments by integrating capabilities across provider engagement and training, member engagement and experience, health improvement programs, administrative excellence and rigorous data analytics. Develop analytic and reporting plan and capabilities, organization and governance structure, operationalize and continuously drive results
  
Develop and deploy multi-year strategy to optimize risk adjusted revenue, integrating risk-adjustment and Star improvement activities with members’ healthcare. Ensure financial lever performance targets across Medicare Stars, and risk adjustment.
         
Enable optimal Star ratings across the Medicare portfolio, developing capabilities that support data-driven change in desired member and provider behaviors, process excellence in health plan activities, and improved member experience. Develop and implement new efforts to improve member engagement and satisfaction.

Represent CareFirst’s Medicare and Medicaid programs to various external and internal audiences and stakeholders.

Allocate capital and human resources and establish operating accountabilities, parameters and priorities. Oversee the recruitment, development and retention of effective team members at multiple levels.  Ensure the department maintains a quality workforce equipped with the skills and competencies needed to fulfill its mission. Completes other assignments as required by Executive Vice President, Medical Affairs.

SUPERVISORY RESPONSIBILITY: 

This position leads a small team including a clinical leader, care coordinators and analysts.  

SCOPE DATA:  Position is accountable for all program development, implementation and day to day operational execution Stars and Risk Adjustment as related to Medicare and Medicaid books of business.