AVP, National Medical Director – Stars and Risk Adjustment

Darum lohnt es sich

• Provide clinical leadership and strategic direction for STARS and Risk Adjustment initiatives • Drive provider engagement and satisfaction related to risk adjustment and clinical quality programs • Oversee risk adjustment education • Develop, implement, and monitor KPIs, reporting, and education for Regional Vice Presidents and Health Services Directors • Engage and partner with physicians, physician groups, and market leadership • Consult on quality and measurement of care delivery programs • Provide clinical guidance and subject matter expertise across STARS and Risk Adjustment initiatives • Oversee medical direction for Stars self-reporting metrics, including clinical oversight, interpretation, and escalation • Participate in CMS audits with physician-level clinical expertise • Provide targeted provider education to close Stars gaps and improve quality-measure performance • Lead and manage the risk adjustment education team • Collaborate with operations, clinical, analytics, and compliance stakeholders • Oversee education sessions, materials, and resources for internal teams and provider partners • Analyze data and trends to identify process improvements and provider engagement opportunities • Ensure regulatory, policy, and quality compliance • Serve as physician signatory for provider disclosure letters related to modified claims and new diagnoses • Assist with provider reporting, education, and feedback loops supporting accurate documentation and compliant risk adjustment practices Requirements • Advanced clinical degree (MD, DO) required • Demonstrated experience in clinical leadership roles, preferably within managed care, risk adjustment, or quality improvement environments • Experience with risk adjustment and STARS • Ability to lead and develop high-performing teams • Strong communication and relationship-building skills with experience engaging provider organizations • Experience developing and monitoring KPIs, reporting, and educational programs for healthcare leaders • Proficiency in interpreting clinical and quality data to drive performance improvement • Minimum internet speed of 25 Mbps download and 10 Mbps upload for home or hybrid home/office employees • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information • Occasional travel to Humana offices for training or meetings may be required Core Competencies Demonstrates advanced clinical leadership and strategic direction in STARS and Risk Adjustment initiatives, with a focus on provider engagement, quality improvement, and compliance.

Highest-signal resume keywords • Advanced Clinical Degree (MD, DO) • Clinical Leadership Experience • Risk Adjustment Expertise • KPI Development and Monitoring • Strong Communication Skills ATS Optimization Keywords Hard Skills • Clinical Oversight • Data Analysis • Quality Improvement • Performance Improvement • Education Program Development • Regulatory Compliance • Risk Adjustment Education • STARS Metrics Interpretation • Provider Engagement • Healthcare Reporting Soft Skills • Relationship-Building • Team Leadership • Collaboration Industry Keywords • Managed Care • CMS Audits • Healthcare Compliance • Clinical Quality Programs • Provider Disclosure • PHI/HIPAA Compliance Proficient in developing KPIs and educational programs while ensuring regulatory adherence and effective communication with healthcare stakeholders.