Medicare Quality & Risk Adjustment Program Lead

Job not on LinkedIn

🕒 July 2

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Montage Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Montage Health is a family of health organizations situated in Monterey County, designed to keep people healthy and connected. As a nonprofit entity, it provides a continuum of care that encompasses preventive, restorative, palliative, and coordinated services. The Montage Health family includes various organizations such as Aspire Health, Community Hospital of the Monterey Peninsula, MoGo Urgent Care, Montage Health Foundation, Montage Medical Group, Montage Wellness Center, and Ohana, focusing on youth mental healthcare. With a team of 3,000 members, their shared vision is to improve lives by delivering exceptional care and inspiring optimal health.

📋 Description

• Responsible for operational leadership and coordination of Medicare Advantage Quality, HEDIS, Stars, Risk Adjustment, and audit readiness activities. • Serve 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. • Partner with internal stakeholders, provider organizations, consultants, and vendors to ensure accurate reporting, regulatory compliance, and achievement of organizational quality and risk adjustment goals. • 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. • 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. • 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. • 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.

🎯 Requirements

• 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 processes, 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. • Active, unrestricted Registered Nurse License • Bachelor’s degree in Nursing, Healthcare Administration, Public Health or related field