Crc Risk Adjustment Coder Jobs in Saint Charles, IL

The Senior Director, Medicare Performance Hub (MPH) is a leadership role within the Blue Cross Blue Shield Association (BCBSA) Medicare business operations team. This individual will serve as the primary programmatic owner and operational lead for the MPH - a core enabling function designed to drive performance improvement in the areas of Star Ratings, Risk Adjustment, and Medical Cost Management.
The MPH leader will oversee the build-out, operationalization, and ongoing governance of the Hub, translating national program data and analytic insights into targeted, actionable guidance for Plans. This role sits at the intersection of analytics, clinical performance, provider performance, plan engagement, and vendor management - requiring a leader who can fluently navigate data-driven strategy while managing complex stakeholder relationships across internal BCBSA teams, Blue Health Intelligence (BHI), analytics platform partners, and the Blue System.
The Hub is designed to provide contract-level performance intelligence and member-level insights that enable Plans to execute local actions that improve Stars performance, coding accuracy, and medical cost outcomes. The MPH does not execute locally - it equips, enables, and holds Plans accountable. Plans retain responsibility for direct member and provider engagement; the MPH provides the intelligence infrastructure and consultative support that makes that engagement effective.
The MPH will:
Proactively identify benchmarks and performance targets across Stars, Risk Adjustment, and Medical Cost Management
Monitor performance in real time where data and technology allow, and retrospectively identify gaps and remediation pathways
Deliver actionable, member-level insights to Plans via dashboards and direct consultative engagement
Coordinate with analytics platform partners, BHI, and BCBSA clinical and analytic staff to operationalize performance data
Establish governance and accountability structures, including escalation pathways, corrective action plans, and Plan performance incentive frameworks

Analytics Oversight & Vendor Management
Serve as the business owner and primary BCBSA liaison for the MPH analytics platform vendor, accountable for program and Plan level performance and deliverables against contract terms
Partner with the analytics vendor to build management and operational dashboards providing national, regional, and Plan-specific performance views with drill-down capability to provider, geography, and member level
Collaborate with BHI to develop benchmark and target-setting methodology for the Plan Performance Incentive Program (PIP) across Stars, Medical Cost Management, and Risk Adjustment coding accuracy
Oversee data integration strategies across key data types - including Parts C and D claims, clinical supplemental data, encounters, and Risk Adjustment Files (RAF) - working across FEPOC, BCBSA IT, and Plan data and analytics leads
Manage MPH data access and license strategy for Plans, in coordination with BCBSA IT and the analytics vendor
In coordination with BHI, leverage VRDC, NDW, and other Blue-sourced data to establish program-wide benchmarks and performance targets
Program Leadership & Strategy
Lead the design, implementation, and ongoing management of the Medicare Performance Hub
Develop and execute the MPH operating model, including engagement processes with Plans and vendors, business review cadences, best practice sharing, and escalation/remediation protocols
Establish and manage the MPH governance framework, engaging with Plan CEOs, leadership, BCBSA senior management, and the Board of Managers and Directors as appropriate
Define and maintain MPH scope - distinguishing national programmatic functions from local Plan responsibilities - and ensure alignment across all stakeholders
Plan Engagement & Oversight
Serve as the primary BCBSA relationship lead for Plans on MPH performance matters, establishing a cadence of operational reviews, performance reporting, and consultative engagement
Translate national program insights into Plan-specific action plans; facilitate targeted strategies for Plans requiring performance improvement support
Define and implement the MPH escalation framework, including Corrective Action Plans (CAPs) and Plan performance accountability structures consistent with Plan Participation Agreement (PPA) requirements
Engage with Plan CEOs, CFOs, Government Business Leaders, FEP leads, and clinical and analytic staff at Plans
Represent the MPH in BOM/BOD engagements as required; contribute to program governance discussions
Stars Ratings Oversight
Monitor Plan Stars performance against program benchmarks, identify underperformance trends, and partner with Plans to close care gaps at the member level
Lead the development of Stars analytics build - including provider-, clinical-, and administrative-measure tracking - and ensure actionable target lists and gap closure data are delivered to Plans
Facilitate consultative support for Plans on evidence-based interventions to improve HEDIS, administrative, and Part D Stars measures
Coordinate with BHI on Stars benchmarking and tracking Annual Wellness Visit and recapture rates
Risk Adjustment Oversight
Lead the development of analytic capabilities supporting risk adjustment accuracy, including encounter data submissions, chart review workflows, and in-home Health Risk Assessment (HRA) program performance
Partner with Plans and the analytics vendor to surface Risk Adjustment coding opportunities at the member level, including prospective and retrospective strategies
Support integration of supplemental clinical data sources - including EMR, clearinghouses, and Health Information Exchanges - that feed the MA data repository and inform RA analytics
Monitor RAF performance and coding accuracy trends across Plans; identify patterns requiring programmatic intervention or plan-specific support
Medical Cost Management Oversight
Lead the MPH's medical cost management analytics function, driving insights on readmission rates, ED utilization, high-cost claimants, inpatient and post-acute utilization, and other key cost drivers
Develop and maintain the medical cost performance playbook, in collaboration with clinical operations leads and analytic partners
Partner with Plans on cost trend analysis, root cause identification, and targeted intervention strategy at the member and provider level
Coordinate with Plans on local vendor engagement for last-mile execution (e.g., in-home HRA vendors, care management platforms) where MPH insights identify actionable opportunities
Data Strategy & Cross-Functional Collaboration
Partner with BCBSA IT, FEPOC, BHI, and the analytics vendor to define MPH data requirements - including data elements, formats, frequency, and transmission standards - and represent the MPH's needs in data architecture decisions
Collaborate with the Data Strategy team to ensure MPH analytics requirements are reflected in the MA data repository architecture and Plan data submission standards
Work with BCBSA Legal, Compliance, and Actuarial functions to ensure MPH operating model, data sharing, and incentive structures align with CMS regulations, BCBSA policy, and the PPA

The posting range for this position is:

$198,175.00 - $278,053.00

Qualifications:
Education

• Required BS or equivalent experience
• Preferred MS in Health Administration, Public Health, Business Administration, or a related field preferred

Experience

• Required 12+ Years experience in Medicare Advantage program management, health plan operations, or managed care performance improvement

Knowledge Skills and Abilities

• Required
• Demonstrated expertise in two or more of the following areas: CMS Star Ratings, Risk Adjustment/HCC coding accuracy, or Medical Cost Management (utilization management, care management, medical economics)
• Proven experience managing complex, multi-stakeholder programs involving health plans, analytic vendors, and a national program office function
• Deep understanding of Medicare Advantage data flows including Parts C and D claims, supplemental clinical data, encounter data, and CMS reporting requirements
• Experience with managed care performance analytics and data-driven plan engagement - including the ability to translate data insights into actionable, plan-level guidance
• Strong project management skills with the ability to manage multiple parallel workstreams across internal and external teams
• Excellent written and verbal communication skills, with a track record of presenting complex analytic and operational information to executive audiences
• Preferred:
• Experience working within or supporting a national Blue plan program, EGWP, or the Federal Employee Program (FEP)
• Familiarity with Medicare Advantage analytics platforms, multi-source data integration strategies, and benchmarking using CMS administrative data (e.g., VRDC, MMR, NDW)
• Experience managing health analytics vendor relationships, including contract oversight and deliverable accountability
• Knowledge of CMS audit, compliance, and reporting requirements applicable to Medicare Advantage plan sponsors

Extra Posting Information:

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