Head of Medicare Performance Hub

Overview

Senior Director leading Medicare Performance Hub at BCBSA driving performance improvement in Star Ratings Risk Adjustment and Medical Cost Management. This role translates national program data into actionable guidance for Plans while managing complex stakeholder relationships across internal BCBSA teams BHI analytics partners and the Blue System.

What You'll Do43

• 1Proactively identify benchmarks and performance targets across Stars Risk Adjustment and Medical Cost Management
• 2Monitor performance in real time and retrospectively identify gaps and remediation pathways
• 3Deliver actionable member-level insights via dashboards and consultative engagement
• 4Coordinate with analytics platform partners BHI and BCBSA clinical staff to operationalize performance data
• 5Establish governance and accountability structures including escalation pathways corrective action plans and Plan performance incentive frameworks
• 6Serve as business owner and primary BCBSA liaison for MPH analytics platform vendor ensuring program and Plan level performance against contract terms
• 7Partner with BHI to develop benchmark and target-setting methodology for the Plan Performance Incentive Program across Stars Medical Cost Management and Risk Adjustment coding accuracy
• 8Oversee data integration strategies across claims clinical supplemental data encounters and Risk Adjustment Files collaborating with FEPOC BCBSA IT and Plan data leads
• 9Manage MPH data access and license strategy in coordination with BCBSA IT and analytics vendor
• 10In coordination with BHI leverage VRDC NDW and other Blue-sourced data to establish program-wide benchmarks and performance targets
• 11Lead design implementation and ongoing management of Medicare Performance Hub establishing engagement processes business review cadences and escalation protocols
• 12Define and manage MPH governance framework engaging with Plan CEOs leadership BCBSA senior management and Board of Managers and Directors
• 13Establish and maintain MPH scope distinguishing national programmatic functions from local Plan responsibilities
• 14Serve as primary BCBSA relationship lead for Plans on MPH performance matters translating national insights into Plan-specific action plans
• 15Translate national program insights into Plan-specific action plans facilitating targeted strategies for performance improvement
• 16Define and implement escalation framework including Corrective Action Plans and Plan performance accountability structures consistent with Plan Participation Agreement requirements
• 17Engage with Plan CEOs CFOs Government Business Leaders FEP leads and clinical analytic staff
• 18Represent MPH in BOM/BOD engagements contributing to program governance discussions
• 19Monitor Plan Stars performance identify underperformance trends and partner with Plans to close care gaps
• 20Lead development of Stars analytics build including provider clinical and administrative measure tracking delivering actionable target lists and gap closure data
• 21Facilitate consultative support for Plans on evidence-based interventions to improve HEDIS administrative and Part D Stars measures
• 22Coordinate with BHI on Stars benchmarking and tracking Annual Wellness Visit and recapture rates
• 23Lead development of analytic capabilities supporting risk adjustment accuracy including encounter data submissions chart review workflows and in-home Health Risk Assessment program performance
• 24Partner with Plans and analytics vendor to surface risk adjustment coding opportunities at member level
• 25Support integration of supplemental clinical data sources feeding MA data repository informing RA analytics
• 26Monitor RAF performance and coding accuracy trends across Plans identifying patterns requiring programmatic intervention
• 27Develop and maintain medical cost performance playbook collaborating with clinical operations leads and analytic partners
• 28Partner with Plans on cost trend analysis root cause identification and targeted intervention strategies at member and provider level
• 29Coordinate with Plans on local vendor engagement for last-mile execution where MPH insights identify actionable opportunities
• 30Partner with BCBSA IT FEPOC BHI to define MPH data requirements including data elements formats frequency and transmission standards
• 31Collaborate with Data Strategy team to ensure MPH analytics requirements are reflected in MA data repository architecture
• 32Work with BCBSA Legal Compliance and Actuarial functions to ensure MPH operating model aligns with CMS regulations BCBSA policy and PPA
• 33Demonstrated expertise in CMS Star Ratings Risk Adjustment or Medical Cost Management
• 3412+ years experience in Medicare Advantage program management health plan operations or managed care performance improvement
• 35Expertise in managing multi-stakeholder programs involving health plans analytic vendors and national program office functions
• 36Deep understanding of Medicare Advantage data flows including Parts C and D claims supplemental clinical data encounter data and CMS reporting requirements
• 37Experience with managed care performance analytics and data-driven plan engagement translating insights into actionable guidance
• 38Strong project management skills managing multiple parallel workstreams across internal and external teams
• 39Excellent written and verbal communication skills presenting complex analytic and operational information to executives
• 40Preferred: Experience within national Blue plan programs EGWP or Federal Employee Program familiarity with Medicare Advantage analytics platforms multi-source data integration and benchmarking using CMS administrative data
• 41Familiarity with health analytics vendor relationships contract oversight and deliverable accountability
• 42Knowledge of CMS audit compliance and reporting requirements for Medicare Advantage plan sponsors
• 43#LI-Hybrid

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