- Program Leadership
- Function as the leader and champion of the Medicare Stars Program, risk adjustment operations, and Medicare cost of care initiatives.
- Collaborate with internal and external stakeholders to establish measure by measure targets for the 50+ clinical, experience and administrative measures in support of the overall contract-level Stars goal.
- Develops targets for key operational metrics to drive improvement in risk score accuracy. Works with Finance to forecast risk scores for each contract, plan, and member segments.
- Develops and evolves the programs operating model, leveraging and defining responsibilities for internal resources, vendors, the provider network, provider enablement entities, and external partners to drive performance.
- Educates stakeholders, partners and vendors about Stars and Risk Adjustment program requirements and drive performance to meet expectations.
- Define and implement processes for monitoring key operational performance metrics and establish processes for managing vendor relationships, monitoring vendor performance, and provider performance.
- Maintains a deep understanding and educates stakeholders on CMS requirements and regulations related to the Medicare Stars Program, risk adjustment methodologies, coding guidelines, and operational best practices.
- P&L Strategy
- Builds and executes a strategy to achieve 4+ star rating and reach annual benchmark for risk adjustment coding accuracy and quality, optimize cost of care, and maintain compliance with CMS regulations.
- Develops provider engagement and performance management strategies to close care gaps and enhance clinical documentation. Collaborates with leadership in finance, and provider network management to develop provider performance incentives, and value-based payment models for providers, physician organizations, health systems, and/or provider enablement entities.
- Align Stars activities and interventions with HCC risk adjustment initiatives to optimize care improvement opportunities with revenue management.
- Present updates on Stars performance and quality outcomes relative to the program strategy to executive leadership, staff, and other audiences as required.
- Analytics and Performance Management
- Develop and evolve analytic capabilities to support performance tracking, identify performance opportunities, diagnose drivers of underperformance, and provide actionable insights.
- Oversee the production of the Stars and Risk Adjustment performance dashboards which monitors and reports ongoing performance against targets; ensure ongoing analysis of performance at the contract level, the domain level and at the measure level; make recommendations to adjust goals and targets, as necessary.
- Develop process for tracking projected and realized savings associated with cost of care initiatives, in collaboration with Financial Planning and Analysis team. Tracks implementation status, risks, and financial assumptions for cost of care initiatives.
- Cross-Functional Integration and Communication
- Provide strategic oversight and direction to ensure development efforts for Medicare P&L management, clinical quality improvement projects, member experience improvement projects, and member and provider engagement activities are coordinated and aligned to support HMSA's performance goals. Coordinate and direct designated liaisons with the implementation of the operating plan, including leadership and staff from Provider Engagement, Provider Operations, Internal Operations, Medicare Programs, Health Management, Pharmacy Management, Finance, our drug PBM and other partners/vendors.
- Oversee internal cross-functional teams and external partner collaborations on P&L performance improvement activities.
- Management and Leadership
- Manage program staff in assignment of projects and work, performance management, career development, compensation, recruitment, training and development.
- Prepare and monitor unit plan and budget for area of responsibility. Review budget versus actual expenditures.
- Adjusts processes for both operational and strategic activities that are related to procedures, workflows, and other business activities that impact employee productivity and morale.
- Functions as a leader in Medicare Programs department and cross-functional leadership teams, helping to lead the department and organization toward meeting its goals, mission and vision.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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HMSA
Mar 27, 2026