AVP, National Medical Director – Stars and Risk Adjustment

• 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. Proficient in developing KPIs and educational programs while ensuring regulatory adherence and effective communication with healthcare stakeholders.

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