Medicare Advantage Program Director

AllCare Management Services•Grants Pass, OR

5d•$120,000 - $150,000•Onsite

About The Position

This role offers significant growth potential as the Medicare population continues to expand. You will have the chance to move beyond traditional Medicare Advantage operations and step into a space defined by innovation, as we are currently at a major turning point integrating AI tools to reshape how we manage the domain. As a key part of this evolution, you will help build a robust data lake and repository designed to centralize member electronic medical records, supporting critical internal processes and the rollout of AI-driven audits and data set analysis. Success in this position requires a sharp analytical mindset. You will be responsible for ensuring the business line stays aligned with bid and budget targets while driving performance in Star ratings and risk adjustment gap closures. The Medicare Advantage Program Director is responsible for the mechanical and financial integrity of our Medicare Advantage (MA) line of business. This role focuses on the back-end systems that drive the program: the annual bid process, Star ratings, risk adjustment data flow, and the accuracy of our clinical documentation. You will ensure our data is audit-proof and that our financial performance matches our strategic goals; while also identifying the opportunities we need to grow our market share.

Requirements

Significant experience leading the operational side of a Medicare Advantage Plan.
Expert knowledge of the CMS-HCC risk adjustment model and the Stars program.
Proven ability to manage a budget and oversee complex financial data reconciliations.
Comfort working with large-scale data extracts and translating them into actionable operational plans.
A focus on accuracy, from the June bid submission and revenue reconciliation down to the last cent of a provider incentive payment.
The ability to trace how a regulatory or coding shift at the federal level translates into a direct financial impact on our local operations and the communities we serve.
A track record of meeting strict federal deadlines while maintaining high standards for data integrity.
7–10+ years of experience in healthcare administration, with significant experience in Medicare Advantage
Strong knowledge of CMS regulations, risk adjustment, and value-based care models
Experience with healthcare analytics, quality improvement, and financial management
Bachelor’s degree in Health Administration, Business Administration, Public Health, or related field (Master’s degree preferred)
MA Leadership: Significant experience leading the operational side of a Medicare Advantage Plan.
Valid Oregon Driver’s License and vehicle insurance.
Familiarity with the Healthcare industry.
Exceptional writing, editing, and proofreading skills.
Excellent organization and time-management skills.
Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
Knowledge of and compliance with HIPAA regulations.
Knowledge of project management and/or change management.
Promotes honesty, transparency, and diligence. Approaches leadership with mindset of “power with” rather than “power over” and regularly includes others in planning and decision-making. Able to make and communicate difficult decisions in the best interest of AllCare Health.
Ready to take advantage of unexpected opportunities; adapts quickly to change and is a teacher to assist with change within the organization. Commits to solving unresolved issues in an effort to collaborate and model problem solving. Proactively develop solutions to challenges, including by constantly looking at big-picture progress and thinking about people.
Enthusiasm for meeting and engaging with people. Able to put people at ease, especially when there are lines of difference. Identifies and intervenes in problematic dynamics. Listens closely to understand needs or concerns and takes steps based on that input. Gets back to people in a timely manner. Takes pride in providing clear and helpful information.
Brings a clear vision and recognizes the value of divergent perspectives. Provides equity-centered conflict transformation support, interventions, and training in the team and across departments. Commits to and understands concepts of equity, belonging, and inclusion in the workplace. Effectively works and collaborates across differences. A working knowledge and understanding of the ways implicit bias, personal identity, and power and privilege impact individuals, organizations and systems.

Nice To Haves

Master’s degree preferred
Being bilingual in another language, including American Sign Language (ASL), is an invaluable skill that enhances our ability to deliver culturally responsive care.

Responsibilities

Direct the cross-functional effort to complete and submit the annual bids.
Be responsible for the accuracy of our coding data and ensure that every diagnosis is backed by clinical evidence in the record.
Manage the quantification and processing of provider incentive payments. Oversee specialists analyzing data extracts to ensure accurate, timely payouts.
Maintain a continuous state of audit readiness for RADV and other federal reviews. Be the final check on the integrity of our clinical data repositories.
Manage the operational side of quality metrics, ensuring the data systems for closing HEDIS and CAHPS gaps are functioning correctly.
Monitor and implement all CMS regulatory changes to ensure the MA line remains in total compliance with federal law.
Maintains punctual, regular and predictable attendance.
Works collaboratively with the Director of Equity & Tribal Partnerships on quality measures.
Respectfully takes direction from leadership.
Meets all required training including those listed in Relias Learning Module System (LMS).
Performs other duties as assigned.