The posting
Summary
Why should you join the BlueCross BlueShield of South Carolina family of companies?
Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
As the Medicare Advantage Quality and Risk Performance Officer, you will work closely with the leadership team to oversee all related activities for Star rating improvement functions. As an innovative thought leader, you must diagnose performance gaps to define organizational strategy and craft annual and long-term plans for improvement. The Medicare Advantage Quality and Risk Performance Officer must use tactical execution to draw conclusions from data, track trends, and determine solutions to identify, create, track, report and manage Stars rating initiatives. The Officer should also be able to clearly articulate solutions, challenges, and results to executives in a professional and formal style.
In addition to Stars expertise, we are seeking a results-driven professional with experience in Medicare Advantage risk adjustment and value-based healthcare programs to support performance optimization and revenue integrity. The ideal candidate will have a strong understanding of HCC coding, RAF score optimization, and CMS regulatory requirements, with a proven ability to translate data insights into actionable strategies. Responsibilities include leading risk adjustment initiatives, supporting audit readiness (e.g., RADV), and identifying opportunities to enhance coding capture and care gap closure. Experience working with value-based arrangements, including shared savings models and provider incentive programs, is highly preferred. The candidate should bring a balance of analytical rigor, operational execution, team-building and strategic thinking to advance performance in a complex, highly regulated environment. In addition to hands-on involvement with Stars, Risk Adjustment and Value-based programs, the Officer must be able to foster positive team morale, inspire others to achieve challenging objectives and be extremely collaborative across departments. This is an essential role designed for leaders who want the opportunity to achieve great outcomes.
Description
Location: This position is full-time (40-hours/week) Monday-Friday working ONSITE at our Government Programs Complex at 17 Technology Circle, Columbia, SC location.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You’ll Do:
- Develop and implement strategic plans to improve the Stars ratings for Medicare Advantage programs.
- Ensure that plans are continuously evaluated and any modifications are implemented in a timely manner.
- Build relationships with, and lead, cross-functional teams to drive Stars rating initiatives and best practices by promoting innovation, strategy development, and implementation excellence.
- Effectively communicate performance progress, new initiatives needed for higher performance, organizational barriers, and expectations of results to senior leadership.
- Develop reports for senior leaders and internal stakeholders. Present findings of improvement efforts, ongoing performance measures, and recommended actions plans.
- Build and maintain effective relationships with providers and vendors.
- Develop and implement strategies to engage, education, and motivate providers. Effectively manage vendors and hold them accountable for high performance.
- Drive positive culture transformation and corporate-wide awareness of Stars through education, communication, and employee engagement.
- Develop and refine internal education. Stay abreast of, and keep the organization apprised of, existing and new legislation impacting Stars ratings.
- Provide oversight to Stars team.
To Qualify for This Position, You'll Need the Following:
- Required Education: Bachelor's degree.
- Required Experience:10 years of experience in insurance, healthcare, or similarly complex industry; Concurrent experience includes: 5 years of health plan experience; 3 years of management experience OR 3 years of equivalent military experience in grade E4 or above; 3 years of Medicare Advantage Stars Rating program experience.
- Required Software and tools: Microsoft Office suite, including advanced PowerPoint and Excel skills
- Required Skills and Abilities:Ability to effectively lead organization wide initiatives. Ability to develop and lead high performing team. Excellent communication and interpersonal skills. Ability to set priorities, meet objectives for complex projects involving multiple stakeholders, and execute according to plan. Ability to build effective relationships with cross-functional teams and external stakeholders. Ability to work across all levels of the organization, including work with individual contributors, executive and management audiences, physicians and vendors.
We Prefer That You Have the Following:
- Stars leadership position in a high performing (4+ Stars) Medicare Advantage health plan. Hands-on Risk Adjustment and value-based program experience.
- Master's degree or RN.
- HEDIS experience.
Our Comprehensive Benefits Package Includes The Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
- Subsidized health plans, dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
What to Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
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