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.
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.
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.
Bachelor’s degree in Business or related field. 10 to 15 years of related experience and 8 to 10 years of increasingly responsible management experience; or an equivalent combination of education, health care, or health insurance management experience with increasing management responsibilities.
In addition, at least 5 years’ experience in the oversight of Medicare related programs in a health plan/payor environment, with thorough knowledge of Stars and risk adjustment.
Management experience in managed care operations.
Proven ability to lead with an equal balance of strategic agility and execution rigor.
Demonstrated leadership effectiveness in both formal and influencer roles; dynamic leader that motivates and inspires teams to achieve challenging targets.
Must possess superior management, negotiation and analytical skills.
Requires the ability to develop and maintain strong internal and external relationships.
Must possess excellent verbal and written communications skills.
MA Implement - Medical
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. The associate must frequently travel to other CareFirst BlueCross BlueShield locations.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
Internal Number: 13134
About CareFirst BlueCross BlueShield
CareFirst is the health care marketplace leader in more ways than one. We are the largest health care insurer in the Mid-Atlantic region, employing more than 5,000 associates and serving nearly 3.4 million members in Maryland, the District of Columbia and Northern Virginia.We are also innovation leaders – our associates are continually finding creative and effective ways to deliver greater value and service to our members and improve the quality of life in our communities. The new normal for the health care industry is constant change and evolution and CareFirst strives to drive the future of health care through our advanced solutions.We promote learning and development by encouraging and supporting our associates to invest in their own learning and development. We are guided by a powerful set of values that inform and influence our interactions with each other, our members and our community.