Program Manager, Risk Adjustment – Stars

Job Description:

• Own the annual risk adjustment and Stars improvement program cycle across prospective and retrospective programs, visit-based campaigns, and gap closure workflows
• Build and manage program timelines and throughput; report progress to Alpine leadership and health plan partners
• Lead cross-functional workgroups spanning coding/HCC, clinical quality, IT, and analytics
• Manage program documentation and requirements, translating technical specifications into operational plans
• Liaise between coding/data teams and operational stakeholders on HCC capture, chart review, and gap identification workflows
• Manage vendor relationships and coordinate technical file exchange and integration needs
• Monitor RAF score trends and performance results and translate findings into operational action plans
• Coordinate risk adjustment data submission accuracy and EDS reconciliation
• Track HCC model version transitions and communicate operational and financial impacts
• Coordinate Star Ratings strategy across HEDIS, CAHPS, HOS, and medication adherence measures
• Partner with analytics teams on performance tracking, cut-point modeling, KPIs, and dashboards
• Serve as a point of contact with health plan Stars/quality teams
• Identify and escalate data integrity issues across claims, EHR, and supplemental data feeds
• Present performance results and program recommendations to executive leadership and payer partners
• Ensure compliance with CMS regulations, ICD-10-CM coding guidelines, and company policies
• Support RADV audit readiness and health plan data validation requests

Requirements:

• Bachelor's degree in health informatics, data analytics, healthcare administration, business, or related field required
• 5 to 7 years of experience in Medicare Advantage risk adjustment and/or Star Ratings/quality improvement
• Working knowledge of CMS HCC risk adjustment models, RAF score methodology, EDS submission processes, and Star Ratings measure specifications
• Demonstrated ability to work with technical teams and operational/business stakeholders, translating between the two
• Proven program/project management experience managing cross-functional technical and operational initiatives
• Working proficiency in Excel required
• Strong written and verbal communication skills
• Strong relationship management and cross-functional collaboration skills
• Ability to interpret data and technical findings and turn them into operational plans
• Ability to adapt to evolving CMS methodology and health plan requirements
• Ability to travel to meetings
• Ability to handle multiple demands concurrently in a high-stress environment, organize, coordinate, set priorities, and meet deadlines
• HIPAA-compliant home office for remote or telecommuting positions
• CRC credential, value-based care/ACO/delegated risk experience, familiarity with multiple health plan Stars/quality programs, PMP or similar certification, and SQL/Tableau/Power BI familiarity preferred or a plus

Benefits:

• Eligible for annual bonus based on individual and/or company performance
• Medical insurance
• Dental insurance
• Vision insurance
• 401(k)
• Paid time off (PTO)
• Employee Assistance Program (EAP)
• HIPAA-compliant home office for remote or telecommuting positions