Senior Director, Risk Adjustment And Quality

About Blue Cross

Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us.

How Is This Role Important to Our Work?

The Senior Director for Risk Adjustment is responsible for leading enterprise development of the Medicare Star Ratings and Enterprise Risk Adjustment strategies that ensure our risk adjusted and Star members are getting the right clinical and pharmacy care at the right time.

This leader drives cross-divisional execution of a multi-year strategy to achieve and maintain a Star Rating of 4+ and ensure risk score accuracy and completeness in all enterprise risk adjustment activities. Development of 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. Operational integration and coordination with impacted divisions within Blue Cross to ensure support and coordination with existing health plan programs and functions including medical management, claims payment, consumer experience, product development, network management, data and analytics, grievance and appeal management, and customer service to drive successful integration with the Risk Adjustment strategy. The Senior Director will work in close collaboration with executive leadership of Blue Cross representing Medical Management, Sales, Product Development, Underwriting, Actuarial, Finance, Network Management, Government Programs, Operations, and other divisions. The role may involve interaction with leadership of integrated delivery systems, hospitals, clinics, and other health care provider organizations, and with trade associations. Other key external relationships will be with the Blue Cross and Blue Shield Association and other Blue Cross Blue Shield plans.

A Day in the Life:

• Lead enterprise efforts to maximize the Medicare CMS Star Rating and other quality programs supporting commercial, ACA, and Medicaid lines of business.

• Ensure complete, compliant, and accurate risk scores in all risk-adjusted market segments. Develop a multi-year strategy in collaboration with organizational stakeholders including Health Care Management, Member Services, Network Operations, and other business units as needed to drive process change across the organization to improve performance.

• Lead the strategic direction of quality assurance, coding, submissions, and audit services for risk adjustment revenue optimization.

• Develop roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Collaborate with analytics team to measure the effectiveness of initiatives and process improvements.

• Track and report on initiative progress at all appropriate levels of the organization; creating or joining the necessary forums to do so.

• Coordinate with existing vendors, and/or identify and implement new vendors, in order to drive desired outcomes in risk-adjustment activities.

• Coordinate activities of Star improvement and risk adjustment accuracy and completeness such that maximum benefit is derived with minimized provider and member abrasion.

• Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing clinical, operational, and member experience quality.

• Create and lead cross-departmental initiatives to change processes such that members experience improved satisfaction with the health plan and are less inclined to dis-enroll.

• Oversee PBM clinical Star-related clinical operations and ensure clinical initiatives for regulatory compliance and organizational alignment (i.e., Drug Adherence Programs).

• Directs the team, including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.

Nice to Have:

• Bachelor's / master's degree in business, health care administration, health policy or other relevant discipline.

Required Skills and Experiences:

• Accepting this director level position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.

• 7+ years of related professional experience, with 3+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.

• Strong knowledge of Medicare Star Ratings and risk adjustment programs

• Demonstrated ability to lead cross-functional teams through a dynamic strategic planning process that maximizes opportunities to meet business objectives.

• Superior executive level communication, facilitation, and presentation skills.

• Ability to navigate ambiguity in a complex and matrixed environment.

• Must be a strategic problem solver, with a high level of intellectual curiosity and openness to change.

• Proven leadership ability exemplified by a capacity to think strategically and implement tactically to consistently deliver results, well-developed skills in diplomacy and collaboration.

• Excellent communication, interpersonal and presentation skills.

• Candidates must possess the highest ethical standards and share the organization's commitment to the key values under which it operates. These key values are Respect, Accountability, Imagination, and Courage.

• Excellent relationship skills to partner on shared goals with other Blue Cross teams and colleagues as well as with external key influencers.

Role Designation:

Hybrid Remote

Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite.

Make a difference

Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.

Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.

All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.

Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.