Senior Manager, Risk Adjustment Operations and Performance Improvement

Clever Care Health Plan•Huntington Beach, CA

6d•$127,000 - $160,000•Hybrid

About The Position

The Senior Manager, Risk Adjustment Operations and Performance Improvement leads the operational and analytics-informed execution of Medicare Advantage Risk Adjustment (RAF), Stars, HEDIS, and CAHPS initiatives to improve quality outcomes, coding accuracy, member experience, and financial performance. This role oversees day-to-day program operations, provider performance management, vendor oversight, reporting, and cross-functional execution of key initiatives. Working closely with Provider Relations, Care Management, Pharmacy, Network Management, Compliance, Analytics, and other business partners, this position ensures operational plans are executed effectively, performance targets are monitored, and program activities remain aligned with organizational priorities. The role blends program execution, operational analytics, and continuous improvement while serving as a key liaison between strategic direction and frontline implementation.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Nursing, or a related field.
Five to eight years of experience in Medicare Advantage, managed care, health plan operations, quality improvement, risk adjustment, or population health.
Minimum of three years of leadership experience managing teams, projects, or operational programs.
Experience leading Stars, HEDIS, CAHPS, Risk Adjustment, provider performance, or quality improvement programs.
Experience working with delegated provider organizations, IPAs, medical groups, and PCPs preferred.
Health plan experience strongly preferred.
Strong knowledge of Medicare Advantage, Stars, HEDIS, CAHPS, Risk Adjustment, and provider engagement programs.
Ability to translate analytics into operational action plans
Experience with operational reporting, dashboard review, and performance monitoring.
Strong project management, program execution, and operational follow-through capabilities.
Proven ability to coordinate cross-functional initiatives and manage competing priorities.
Ability to present performance results, operational risks, and recommendations to senior leadership.
Excellent communication, relationship management, and provider engagement skills.
Proficiency with Excel, Power BI, and business intelligence reporting tools preferred.

Nice To Haves

Current coding certification in one or more of the following is strongly preferred: CPC, CPC-H, CPC-P, CCS, CCS-P, or CCA.

Responsibilities

Lead operational execution of Medicare Stars, HEDIS, CAHPS, and Risk Adjustment programs.
Develop annual operational workplans and performance goals that support organizational quality and RAF objectives.
Coordinate cross-functional implementation of initiatives across Provider Relations, Care Management, Pharmacy, Network Management, Compliance, and Operations.
Use performance data and analytics to drive timely execution of interventions to close quality and coding gaps.
Identify operational barriers and implement corrective action plans to improve outcomes, efficiency, and accountability.
Support operational readiness for CMS, NCQA, HEDIS, RADV, and internal audit activities.
Manage provider performance improvement initiatives across delegated and non-delegated networks.
Support provider engagement strategies, including provider scorecards, incentive programs, education, office outreach, and performance reviews.
Partner with Provider Relations to implement targeted interventions for underperforming IPAs, medical groups, and PCPs.
Monitor provider-specific Stars, HEDIS, Risk Adjustment, and CAHPS performance metrics and recommend operational improvement opportunities.
Support implementation of provider incentive and quality improvement programs that improve engagement, accountability, and performance outcomes.
Oversee development and maintenance of operational dashboards, scorecards, and performance reports.
Analyze Stars, HEDIS, RAF, CAHPS, utilization, and provider performance data to identify trends, risks, and improvement opportunities.
Monitor key performance indicators and communicate actionable insights, trends, and operational risks to leadership.
Partner with Analytics and IT teams to improve reporting automation, data quality, and accessibility.
Use data insights to prioritize interventions, guide resource allocation, and support performance improvement strategies.
Translate performance data into practical recommendations for operational teams and providers.
Ensure programs are designed and executed in alignment with CMS, NCQA, and regulatory requirements, with compliance embedded into operational planning.
Use audit findings, including HEDIS, RADV, and coding audits, to inform enterprise improvement strategies and risk mitigation plans.
Drive continuous improvement by integrating audit insights into provider engagement and operational interventions.
Oversee day-to-day vendor performance for coding, abstraction, outreach, quality improvement, and supplemental data initiatives.
Ensure vendor deliverables meet established service-level expectations, timelines, and quality standards.
Monitor program outcomes and operational KPIs to maximize effectiveness, efficiency, and return on investment.
Coordinate implementation, escalation, and issue resolution across internal teams and external partners.
Establish and monitor operational KPIs supporting Stars, Risk Adjustment, HEDIS, and CAHPS performance.
Lead routine performance reviews and operational governance meetings to maintain focus, accountability, and timely follow-through.
Identify opportunities for workflow optimization, process standardization, and improved operational consistency.
Support implementation of technology solutions and automation initiatives that improve efficiency and program outcomes.
Ensure operational reporting and provider communications are accurate, timely, and consistent.
Collaborate with internal stakeholders and external partners to support successful program execution.
Participate in provider meetings, joint operating committees, and engagement events as needed.
Support Quality department representation in health fairs and member engagement activities.
Lead and develop a team responsible for quality and risk adjustment operations.
Establish clear goals, accountability measures, and development plans that support team performance and growth.
Promote collaboration, operational excellence, and a culture of continuous improvement.
Support staff training related to CMS, NCQA, Stars, HEDIS, Risk Adjustment, and provider engagement activities.