Vice President, Risk Adjustment and Quality

Vice President, Risk Adjustment and Quality

Accountable for developing continuous improvement strategies and directing implementation that delivers operational excellence, resulting in high performance in CMS Star and Medicare Risk Adjustment (MRA) program. Support activities and processes related to compliance with CMS, HPMS, NCQA, local, state, and federal regulatory authorities. Manage the MRA Sweeps and encounter data submission activities along with managing annual HEDIS submission for Managed Care Organizations, Medicare Star, HOS, CAHPS, and other regulatory and contractual compliance.

Provide oversight and leadership of Quality Management, including Behavioral Health, Performance Improvement and initiatives, Regulatory Quality Programs, and Member Engagement functional areas. Ensure cross-functional collaboration that meets the accurate & appropriate codes submission goal and also improves quality of care delivery, member experience and outcomes.

• Develop strategy and tactical processes, in collaboration with the Clever Care’s internal teams and Physicians/IPA/MSO partners, to operationalize and execute MRA and HEDIS/Star procedures including, but not limited to, prospective programs, concurrent/retrospective review, submissions, submission reconciliation, quality control and compliance.
• Oversee the formulation, direction, implementation, administration, supervision, and planning of enterprise-wide performance measurement-based strategies relative to MRA and Quality measures.
• Drive the definition, measurement, and implementation of process improvement activities and projects in support of corporate goals.
• Direct the review and analysis of data to evaluate clinical and administrative service improvement activities and programs.
• Evolve MRA and Star program strategy to achieve improved and cost-effective results, while eliminating sources of uncertainty.
• Design, implement, and monitor incentive programs for both Quality and Risk Adjustment initiatives, ensuring alignment with organizational goals and CMS compliance.
• Develop performance-based incentive structures for providers, IPAs, and internal teams to improve HEDIS, CAHPS, HOS, and Risk Adjustment outcomes.
• Analyze incentive program effectiveness through data-driven metrics and adjust strategies to maximize impact on Star Ratings and MRA performance.
• Partner with IT and Data Analytics teams to optimize risk adjustment models, predictive analytics, and dashboard reporting.
• Oversee all critical program vendors, including setting the strategy on outsourcing vs. in sourcing, assessing new partner opportunities, initiating new relationships, and managing performance of existing partners.
• Responsible for ensuring that the definition and formulation of data-driven strategies, as well as the management and operational activities across Quality Management, Medical Management, Pharmacy Services, and other areas of the organization are designed to increase Clever Care Health Plan quality ratings (Medicare Star Ratings, Quality Incentive Awards, and Quality Rankings) occurs in an efficient and effective manner, and in compliance with NCQA, state and federal regulations and requirements.
• Spearhead the AWV and in-home vendor programs’ execution with appropriate tactics and reporting requirements in place.
• Oversee chart retrieval programs completed by vendor and internal teams.
• Oversee coding and documentation, provider education, sweeps & RADV audit programs and processes.
• Manage HCC improvement and encounter error research/resolution projects.
• Improve core process efficiency, effectiveness, and responsiveness; measure and improve business critical operational KPIs/metrics, especially in the areas of member satisfaction/loyalty/retention, and provider access and availability.
• Direct the application of the Customer and Business data to scope the level of improvement required to impact MRA programs, Star ratings, customer experience and loyalty and bottom-line results.
• Work with appropriate entities (internal or external) to reduce encounter/claims rejects from CMS, any vendor projects, and clearing house(s).
• Support the implementation…