Quality and Risk Performance Officer, Medicare Advantage

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

As the Medicare Advantage Quality and Risk Performance Officer, you will work closely with the leadership team to oversee all related activities for Star rating improvement functions. As an innovative thought leader, you must diagnose performance gaps to define organizational strategy and craft annual and long-term plans for improvement. The Medicare Advantage Quality and Risk Performance Officer must use tactical execution to draw conclusions from data, track trends, and determine solutions to identify, create, track, report and manage Stars rating initiatives. The Officer should also be able to clearly articulate solutions, challenges, and results to executives in a professional and formal style. In addition to Stars expertise, we are seeking a results-driven professional with experience in Medicare Advantage risk adjustment and value-based healthcare programs to support performance optimization and revenue integrity. The ideal candidate will have a strong understanding of HCC coding, RAF score optimization, and CMS regulatory requirements, with a proven ability to translate data insights into actionable strategies. Responsibilities include leading risk adjustment initiatives, supporting audit readiness (e.g., RADV), and identifying opportunities to enhance coding capture and care gap closure. Experience working with value-based arrangements, including shared savings models and provider incentive programs, is highly preferred. The candidate should bring a balance of analytical rigor, operational execution, team-building and strategic thinking to advance performance in a complex, highly regulated environment. In addition to hands-on involvement with Stars, Risk Adjustment and Value-based programs, the Officer must be able to foster positive team morale, inspire others to achieve challenging objectives and be extremely collaborative across departments. This is an essential role designed for leaders who want the opportunity to achieve great outcomes.

Requirements

Bachelor's degree
10 years of experience in insurance, healthcare, or similarly complex industry
5 years of health plan experience
3 years of management experience OR 3 years of equivalent military experience in grade E4 or above
3 years of Medicare Advantage Stars Rating program experience
Microsoft Office suite, including advanced PowerPoint and Excel skills
Ability to effectively lead organization wide initiatives
Ability to develop and lead high performing team
Excellent communication and interpersonal skills
Ability to set priorities, meet objectives for complex projects involving multiple stakeholders, and execute according to plan
Ability to build effective relationships with cross-functional teams and external stakeholders
Ability to work across all levels of the organization, including work with individual contributors, executive and management audiences, physicians and vendors

Nice To Haves

Stars leadership position in a high performing (4+ Stars) Medicare Advantage health plan
Hands-on Risk Adjustment and value-based program experience
Master's degree or RN
HEDIS experience

Responsibilities

Develop and implement strategic plans to improve the Stars ratings for Medicare Advantage programs.
Ensure that plans are continuously evaluated and any modifications are implemented in a timely manner.
Build relationships with, and lead, cross-functional teams to drive Stars rating initiatives and best practices by promoting innovation, strategy development, and implementation excellence.
Effectively communicate performance progress, new initiatives needed for higher performance, organizational barriers, and expectations of results to senior leadership.
Develop reports for senior leaders and internal stakeholders.
Present findings of improvement efforts, ongoing performance measures, and recommended actions plans.
Build and maintain effective relationships with providers and vendors.
Develop and implement strategies to engage, education, and motivate providers.
Effectively manage vendors and hold them accountable for high performance.
Drive positive culture transformation and corporate-wide awareness of Stars through education, communication, and employee engagement.
Develop and refine internal education.
Stay abreast of, and keep the organization apprised of, existing and new legislation impacting Stars ratings.
Provide oversight to Stars team.