Senior Business Process Advisor, RA and Quality

Clever Care Health Plan•Huntington Beach, CA

1d•$91,000 - $100,000•Hybrid

About The Position

The Senior Business Process Advisor, Quality & Risk Adjustment, serves as the primary business and operational liaison between Risk Adjustment, Quality/Stars, Clinical Operations, Provider Relations, Analytics, and Information Technology. This role is responsible for translating business priorities, CMS regulatory requirements, and operational needs into scalable workflows, reporting solutions, and technology enhancements that improve Medicare Advantage performance. The Senior Business Process Advisor leads requirements gathering, business process analysis, system implementation support, user acceptance testing (UAT), reporting validation, and performance analytics across Medicare Stars, HEDIS, CAHPS, Risk Adjustment, Population Health, and provider performance initiatives. This position plays a critical role in ensuring organizational priorities are effectively implemented through data-driven solutions, accurate reporting, and cross-functional collaboration. The role combines business analysis, operational problem-solving, data validation, project coordination, and continuous improvement to support organizational goals related to quality outcomes, member experience, risk score accuracy, regulatory compliance, and financial performance.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Information Systems, Data Analytics, or related field.
Minimum five (5) years of experience in healthcare business analysis, healthcare operations, managed care, Medicare Advantage, or health plan analytics.
Minimum three (3) years of experience supporting Medicare Stars, HEDIS, CAHPS, Risk Adjustment, Population Health, or related programs.
Experience working directly with cross-functional business and technology teams.
Health plan experience strongly preferred.
Medicare Advantage experience strongly preferred.
Medicare Stars and HEDIS reporting and operational support.
Risk Adjustment (HCC/RAF) analytics and reporting.
Provider performance reporting and scorecard development.
Predictive modeling and healthcare analytics.
CMS regulatory interpretation and operational implementation.
Salesforce administration or reporting environments.
Vendor implementation and testing activities.
Advanced SQL skills.
Strong analytical and problem-solving capabilities.
Experience with Power BI, Tableau, Salesforce, or similar business intelligence platforms.
Experience validating reporting logic, measure calculations, and data integrity.
Strong User Acceptance Testing (UAT) leadership and execution skills.
Process mapping and workflow documentation expertise.
Ability to interpret and translate regulatory requirements into technical specifications.
Strong Microsoft Excel skills, including data analysis and reporting.

Responsibilities

Partner with business stakeholders to understand operational challenges, strategic priorities, and reporting needs.
Facilitate requirements gathering sessions with Quality, Risk Adjustment, Clinical Operations, Provider Relations, Analytics, and IT teams.
Translate business objectives into detailed functional and technical requirements.
Create business requirements documents, process flows, use cases, user stories, data dictionaries, and testing plans.
Evaluate existing workflows and identify opportunities for automation, standardization, and operational improvement.
Ensure business requirements remain aligned with CMS, NCQA, HEDIS, Stars, CAHPS, and CMS Risk Adjustment requirements.
Support implementation and enhancement of Medicare Stars, HEDIS, and CAHPS programs through business analysis and reporting solutions.
Analyze measure specifications and CMS technical guidance to ensure accurate operational interpretation and implementation.
Partner with operational teams to develop and maintain gap closure reporting and provider performance dashboards.
Validate quality measure logic and reporting outputs to ensure consistency and accuracy.
Support annual Stars, HEDIS, and CAHPS program readiness activities.
Assist with development of interventions designed to improve member outcomes and Star Ratings performance.
Support expansion and enhancement of Risk Adjustment programs across prospective, retrospective, and concurrent initiatives.
Analyze HCC, RAF, coding, suspecting, recapture, and provider performance data.
Translate CMS Risk Adjustment guidance into actionable business requirements and operational workflows.
Collaborate with coding, analytics, provider engagement, and IT teams to improve data capture and reporting capabilities.
Validate risk adjustment reporting, encounter data, coding outputs, and provider scorecards.
Support RADV readiness initiatives, coding validation projects, and documentation improvement efforts.
Partner with Analytics teams to support implementation and optimization of population health and predictive modeling programs.
Support implementation and operational use of Johns Hopkins ACG and other population health stratification tools.
Analyze population health trends, disease burden, risk stratification, utilization patterns, and intervention opportunities.
Translate predictive analytics outputs into actionable business recommendations.
Identify opportunities to improve outreach effectiveness, care gap closure, member engagement, and clinical outcomes.
Develop and maintain provider performance reporting requirements for IPAs, medical groups, and PCPs.
Support development of provider scorecards related to Stars, HEDIS, CAHPS, Risk Adjustment, utilization, and performance incentives.
Validate reporting logic and performance calculations before deployment.
Partner with Provider Relations and operational teams to identify improvement opportunities.
Analyze provider-level performance trends and support targeted intervention planning.
Lead User Acceptance Testing (UAT) efforts for new applications, reports, dashboards, workflows, and system enhancements.
Develop test plans, testing scenarios, acceptance criteria, and issue logs.
Coordinate testing activities among business stakeholders and technology partners.
Validate data integrity, reporting outputs, and workflow functionality.
Monitor defects, prioritize issues, and coordinate resolution activities.
Support implementation of Salesforce, Cozeva, population health, analytics, and other operational technology solutions.
Interpret CMS, NCQA, HEDIS, Stars, CAHPS, and Risk Adjustment guidance and translate requirements into operational specifications.
Support audit readiness activities, including HEDIS audits, RADV audits, and regulatory reviews.
Ensure reporting and operational processes align with applicable compliance requirements.
Participate in analysis and remediation of audit findings and corrective action plans.
Support cross-functional initiatives from concept through implementation.
Facilitate project meetings, document action items, and monitor deliverables.
Coordinate across business units to ensure successful implementation of operational priorities.
Escalate risks, dependencies, and barriers that may impact project success.
Promote collaboration and alignment among operational, clinical, analytical, and technology teams.