Medicare Advantage Stars SME
About The Position
We are seeking a Medicare Advantage (MA) Stars Subject Matter Expert (SME) with deep knowledge of the Medicare Advantage quality, regulatory, measurement, and performance environment. This individual will serve as a subject matter bridge between Medicare Advantage health plans, quality organizations, data/analytics teams, and technology/product development teams. This is a highly collaborative role for someone who can move comfortably between CMS regulations and technical product requirements, plan quality strategies and data analysis, and business needs and technology development. The ideal candidate is someone who can read a 100-page CMS technical document in the morning and explain to a software developer that afternoon exactly what needs to be built — someone who understands not only what CMS requires, but how those requirements affect a health plan's operations, data, quality strategy, technology, and Star Rating. The strongest candidates combine three capabilities: deep Medicare Advantage Stars expertise, the analytical ability to turn performance results into actionable insight, and the technology/product fluency to translate regulatory and business requirements into working solutions. This role is particularly well suited for a Medicare Advantage quality professional who wants to move beyond traditional quality operations and play a central role in building the next generation of Medicare Advantage Stars technology and analytics solutions.
Requirements
- Bachelor's degree in healthcare administration, public health, business, data analytics, health informatics, nursing, or a related field
- 5 plus years of experience with Medicare Advantage Stars and CMS quality programs, gained at a health plan, healthcare technology company, consulting organization, or similar organization supporting MA plans
- Strong understanding of CMS MA Stars measures (HEDIS, pharmacy, CAHPS, HOS, operational and improvement), methodology, regulations, and quality improvement programs
- Strong analytical and problem-solving skills, with the ability to interpret complex regulatory and technical documents and translate them into practical business and technology requirements
- Excellent written and verbal communication skills, with the ability to communicate effectively across executives, quality leaders, product managers, analysts, engineers, and developers
Nice To Haves
- Experience building healthcare technology products — particularly those involving Medicare Advantage Stars, quality, analytics, or regulatory compliance
- Experience writing detailed business/functional requirements, user stories, acceptance criteria, and data specifications
- Experience with SQL, data warehouses, BI tools, or other healthcare analytics technologies
- Experience with Medicare Advantage quality data sources (HEDIS, CAHPS, HOS, claims, encounter, pharmacy, and supplemental data), and familiarity with CMS Stars Technical Specifications, cut points, and benchmarks
- Experience with MA quality improvement programs and interventions
- Experience working in Agile product environments, collaborating with data scientists and software engineers to build healthcare analytics products
Responsibilities
- Interpret and explain CMS MA and Part D Stars regulations, technical specifications, and guidance — including Advance Notices, Final Rules, Rate Announcements, and Technical Notes
- Assess how changes to Stars measures, methodology, benchmarks, cut points, and weighting affect health plans, and translate those implications into practical terms
- Serve as the internal expert on Medicare Advantage quality measurement and performance improvement
- Define business and functional requirements for MA Stars technology and analytics products, translating regulations and measure specs into data requirements, workflows, and calculations
- Partner with product managers, data scientists, and engineers to ensure technology solutions accurately reflect CMS requirements, reviewing designs and outputs for regulatory accuracy
- Help build tools that identify performance gaps and forecast Star Ratings, and support user acceptance testing to validate Stars-related functionality
- Engage directly with MA health plans to understand their Stars strategies, quality challenges, and data environments
- Analyze plan performance to identify improvement opportunities, gaps, and root causes, and help develop targeted interventions
- Present complex Stars findings clearly to plan executives, quality leaders, and both technical and non-technical audiences
- Analyze MA quality and Stars data to evaluate measure-level performance, benchmarks, cut points, and year-over-year trends
- Collaborate with data analysts and scientists to develop Star Ratings forecasts and quality improvement insights, validating that methodologies align with CMS requirements
- Translate analytical findings into recommendations for health plans and product development teams
- Serve as the key Stars SME across product, technology, analytics, consulting, sales, and client engagement teams
- Educate internal teams on Medicare Advantage Stars requirements and emerging regulatory changes, and contribute to client presentations and proposals
- Help establish best practices for incorporating CMS requirements into technology products and identify emerging trends that could shape new capabilities
Benefits
- Customer Success Obsession
- All-Star Team Collaboration
- Continuous Improvement through Curiosity & Data-Driven Learning
- Courage with Kindness
- Execution Focus — We Do Business, Not Just Talk Business
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What This Job Offers
Job Type
Full-time
Career Level
Senior
