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Risk Adjustment Lead - Government Program Development

Employment type: 
Full time
Remote Position: 
Required degree level: 


100% Remote - Full-Time Offsite for designated States

Provides Medicare Advantage Risk Adjustment subject matter expertise, data analysis and strategic perspective to support BCBS Plan competitiveness. Identify opportunities to improve risk adjustment accuracy based on identification of best practices among Plans and in the market. Provides subject matter expertise in support of development of national programs and local Plan (what does this mean when it states Subject Matter Expertise in???) efforts. Interacts with internal and Plan staff to develop and enhance business opportunities including the introduction and sharing of new services, programs, best practices, and innovations (is this statement focusing on account management?).


Responsibilities include but are not limited to:

  • Bachelor's Degree in Business or a related field
  • A minimum of 10 years related business,healthcare, finance or related field.
  • 5 Years Leadership in developing and/or managing Risk Adjustment and Stars component for Medicare Advantage Plans
  • 5 Years Medicare Advantage program development experience
  • 5 Years Experience in independently leading data gathering activities, framing problems and guiding construction of survey instruments through a flexibility, creativity and strategic innovation in development of approaches and methods.
  • 5 Years Leadership experience: ability to lead and guide workgroups and teams to develop consensus on objectives and problem resolution for a broad range of topics and scope.
  • 5 Years Project management experience: ability to prepare work plans and manage mid-sized projects and portions of projects.
  • 5 Years Experience in identifying data/information needs; acquiring and organizing data, delivering analysis and identifying major findings.
  • 5 Years Experience with independently leading data gathering activities, framing problems and guiding construction of survey instruments
  • 5 Years Experience creating and communicating innovative conceptual models and synthesize diverse types of information.


Required Basic Qualifications:

• Leads the identification and development of enhancements of new and existing programs and major projects by conducting regulatory analysis, data analysis, and convening Plans for discussion on opportunities best practices and best practice sharing.• Leads detailed research and interviews to determine feasibility of emerging business opportunities, including impact to business models for various Government Markets business functions (Stars, Risk Adjustment, Provider contracting, provider engagement, performance management, etc.) supporting Medicare business. Collects requirements to develop and analyze reports that supports business needs, and develops strategy, policy and operational recommendations. Develops the required business case and vision based oninput from Sr. Management, Plan executives, user groups, workgroups or governance representatives. Provides leadership within inception and elaboration phases of BCBSA project management methodology, adhering to related project methodology process standards.• Leads mid-sized projects and components of larger multi-year projects to develop and enhance Plan performance in Risk Adjustment. Develops design concepts, policy, and technical operational components. Develops and executes implementation plans as a subject matter expert in risk adjustment.• Manages cross functional efforts through facilitation and communication of new initiatives, requirements, and opportunities. Present findings to internal and Plan staff; participates and leads project team discussions of the conclusions and direction of analytical work.

Preferred Basic Qualifications:

  • Certified Coder is a Plus
  • Subject matter expert in risk adjustment timeline, collaborating with vendor/auditors and understanding regulatory implications and value for risk adjustment.
  • Proficiency in Microsoft Office applications.
  • Analytical expertise in the development and evaluation of reports
  • Project management and group facilitation skills
  • Effective oral and written communication skills
  • Demonstrated knowledge of Medicare Advantage operations
  • Prior experience working with Informatics at a health plan
  • Technically savvy (Power Point, Data Analytics and Excel Spreadsheets)
  • Ability to develop collaborative and supportive relationships with health plans

Equal Opportunity Employer

Blue Cross Blue Shield Association is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, gender identity, disability, veteran status, genetic information or any other legally protected characteristics

Make an impact on healthcare in America. A career with Blue Cross Blue Shield Association allows you to be part of the foundation that supports the 35 Blue Cross and Blue Shield companies nationwide, while protecting and strengthening the Blue Cross Blue Shield brand. Our work is helping provide greater access to cost-effective healthcare, improve the health of America and build stronger communities. With a commitment to diversity, equity and inclusion, we celebrate different cultures, languages, backgrounds and experiences while striving to advance health equity, and we want you to join Team BCBSA.

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