Director of Quality and Risk Adjustment at Ultimate Staffing Services in Los Alamitos, California

Job Description:

Primary Responsibilities

• Lead enterprise efforts to maximize the Medicare CMS Star Rating and other quality programs supporting commercial, ACA, and Medicaid lines of business.


• Ensure complete, compliant, and accurate risk scores in all risk-adjusted market segments. Develop a multi-year strategy in collaboration with organizational stakeholders including Health Care Management, Client Services, Network Operations, and other business units as needed to drive process change across the organization to improve performance.


• Lead the strategic direction of quality assurance, coding, submissions, and audit services for risk adjustment revenue optimization.


• Develop a roadmap that defines the path to operationalize specific actions that are repeatable, measurable, and cost-effective. Collaborate with the analytics team to measure the effectiveness of initiatives and process improvements.


• Track and report on initiative progress at all appropriate levels of the organization; creating or joining the necessary forums to do so.


• Coordinate with existing vendors, and/or identify and implement new vendors, to drive desired outcomes in risk-adjustment activities.


• Coordinate activities of Star improvement and risk adjustment accuracy and completeness to derive maximum benefit with minimized provider and member abrasion.


• Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing clinical, operational, and member experience quality.


• Create and lead cross-departmental initiatives to change processes such that members experience improved satisfaction with the health plan and are less inclined to disenroll.


• Oversee clinical Star-related operations and ensure clinical initiatives for regulatory compliance and organizational alignment.


• Direct the team, including interviewing and hiring employees, ensuring employees receive proper training. Conduct performance evaluations and manage employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.

Required Skills and Abilities

• 7+ years of related professional experience, with 3+ years of management experience. All relevant experience, including work, education, transferable skills, and military experience, will be considered.


• Strong knowledge of Medicare Star Ratings and risk adjustment programs.


• Demonstrated ability to lead cross-functional teams through a dynamic strategic planning process that maximizes opportunities to meet business objectives.


• Superior executive-level communication, facilitation, and presentation skills.


• Ability to navigate ambiguity in a complex and matrixed environment.


• Must be a strategic problem solver, with a high level of intellectual curiosity and openness to change.


• Proven leadership ability exemplified by a capacity to think strategically and implement tactically to consistently deliver results, with well-developed skills in diplomacy and collaboration.


• Excellent communication, interpersonal, and presentation skills.


• Candidates must possess the highest ethical standards.


• Excellent relationship skills to partner on shared goals with other Company teams and colleagues as well as with external key influencers

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. For unincorporated Los Angeles county , to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions. Apply Now