Vice President, STARS and Risk Adjustment

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Vice President of Star and Risk Adjustment will be accountable for the leading enterprise development of the Medicare Star, ACA Quality Rating System and Enterprise Risk Adjustment Strategy. As the VP of Star and Risk Adjustment the incumbent will drive cross-divisional development and execution of a multi-year strategy to achieve a Star Rating of 4+, and revenue optimization across all lines of business (i.e. Medicare and Individual Market). Development of the strategy includes integrating the Star and Risk Adjustment approach to provider engagement, payment and risk sharing models, collaborative care models, data/analytics support, member engagement health improvement and management programs and collaboration with vendor partners to achieve identified goals. This includes effective collaboration with A&R teams to obtain relevant and necessary patient data. The VP of Star and Risk Adjustment will work closely with internal Capital Blue Cross departments to ensure support and coordination with existing health plan programs and functions including medical affairs, claim payment, consumer experience, product development, network management, data and analytics, grievances and appeals management, and customer service to drive successful integration with Stars and Risk strategy.

Responsibilities and Qualifications

• Lead enterprise efforts to optimize the Medicare CMS Star rating, ACA Quality Rating System, and optimize risk-adjusted revenue in all risk adjusted market segments.
• Develop a multi-year strategy in collaboration with organizational stakeholders including Medical Affairs, Member Services, Network Operations, Compliance, Process Improvement, Pharmacy and other critical business units as necessary to drive process change across the organization to improve performance.
• Develop roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Collaboration with analytics team to measure the effectiveness of initiatives and process improvements.
• Coordinate with existing vendors, and/or identify and implement new vendors, in order to drive desired outcomes in quality-based metrics, and risk adjustment activities.
• Lead, coach and instruct process owners and improvement teams in the definition, documentation, measurement, improvement and control of processes aimed at optimizing the quality of the Medicare and ACA programs.
• Create and lead cross-departmental initiatives to change processes to increase the effectiveness of the member experience with the goal of ensuring continued persistence in enrollment and to avoid early disenrollment based on plan dissatisfaction.
• Evaluate the effectiveness of existing operational metrics, developing new metrics as necessary, to better assess the performance of organization in achieving quality, revenue, and satisfaction targets.
• Gather member experience data and conduct analysis to identify gaps, opportunities and performance trends. Utilize information to drive member behavior towards those actions that are expecting to improve health outcomes.
• Track and report on the progress of all Star and Risk initiatives to various levels within the organization to ensure transparent understanding of the opportunities, risks and successes of efforts across the organization.
• Develop a company-wide Star education program that can be easily delivered via digital tools. Support individual units with unit specific training if needed to support key STAR metric understanding.
• Directs the department including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive training and support
• Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relat