AVP, Stars and Risk Adjustment – National Medical Director

Humana

4d • $246,100 - $344,200 • Remote

About The Position

The Associate Vice President, Medical Risk Adjustment and Provider Engagement, is responsible for providing clinical leadership and strategic direction to support the organization’s STARS and Risk Adjustment initiatives. This leader will drive provider engagement and satisfaction, oversee risk adjustment education, and develop, implement, and monitor key performance indicators (KPIs), reporting, and education for Regional Vice Presidents and Health Services Directors.
The Associate VP, Market Consultation/Partnership engages and partners with physicians, physician groups, and market leadership to drive initiatives. Influences and consults on matters related to quality and measurement of care delivery programs with a market(s). Decisions are typically related to intradepartmental coordination, development and implementation of strategic plans, and business outcomes, and develops and implements strategic plans for the scope of management that are aligned with the Segment or Business strategy.

Requirements

• Advanced clinical degree (MD, DO) required.
• Demonstrated experience in clinical leadership roles, preferably within managed care, risk adjustment, or quality improvement environments.
• Risk adjustment and Stars experience
• Proven ability to lead and develop high-performing teams.
• Strong communication and relationship-building skills with experience engaging provider organizations.
• Experience developing and monitoring KPIs, reporting, and educational programs for healthcare leaders.
• Proficiency in interpreting clinical and quality data to drive performance improvement.

Responsibilities

• Provide clinical guidance and subject matter expertise across all STARS and Risk Adjustment initiatives to ensure alignment with organizational objectives and regulatory requirements.
• Demonstrate high responsiveness to providers, with the goal of increasing provider engagement and satisfaction related to risk adjustment and clinical quality programs.
• Serve as the overseeing medical director for Stars self-reporting metrics, including clinical oversight, interpretation, and escalation of issues requiring physician leadership.
• Participate in CMS audits related to Stars and risk adjustment activities, complementing technical and operational audit support with physician-level clinical expertise.
• Provide targeted provider education on clinical and operational areas needed to close Stars gaps and improve performance on quality measures.
• Lead and manage a team dedicated to supporting risk adjustment education, ensuring that materials and communications are accurate, timely, and effective.
• Develop, implement, and monitor KPIs for Regional Vice Presidents and Health Services Directors, ensuring that performance metrics, reporting processes, and educational initiatives support continuous improvement in risk adjustment outcomes and provider engagement.
• Collaborate cross-functionally with internal stakeholders, including operations, clinical, analytics, and compliance teams, to drive the success.
• Oversee the design and delivery of education sessions, materials, and resources for both internal teams and provider partners.
• Analyze data and trends to identify opportunities for process improvements and enhanced provider engagement strategies.
• Ensure that all risk adjustment activities are conducted in compliance with applicable regulations, internal policies, and quality standards.
• Serve as the physician signatory for provider disclosure letters related to risk adjustment when Humana modifies a claim with a new diagnosis, ensuring communications are clinically appropriate and compliant.
• Assist with provider reporting, provider education, and feedback loops to support accurate documentation, improved Stars performance, and compliant risk adjustment practices.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree