Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Vice President of Star and Risk Adjustment will be accountable for the leading enterprise development of the Medicare Star, ACA Quality Rating System and Enterprise Risk Adjustment Strategy. As the VP of Star and Risk Adjustment the incumbent will drive cross-divisional development and execution of a multi-year strategy to achieve a Star Rating of 4+, and revenue optimization across all lines of business (i.e. Medicare and Individual Market). Development of the strategy includes integrating the Star and Risk Adjustment approach to provider engagement, payment and risk sharing models, collaborative care models, data/analytics support, member engagement health improvement and management programs and collaboration with vendor partners to achieve identified goals. This includes effective collaboration with A&R teams to obtain relevant and necessary patient data. The VP of Star and Risk Adjustment will work closely with internal Capital Blue Cross departments to ensure support and coordination with existing health plan programs and functions including medical affairs, claim payment, consumer experience, product development, network management, data and analytics, grievances and appeals management, and customer service to drive successful integration with Stars and Risk strategy.

• Lead enterprise efforts to optimize the Medicare CMS Star rating, ACA Quality Rating System, and optimize risk-adjusted revenue in all risk adjusted market segments.
• Develop a multi-year strategy in collaboration with organizational stakeholders including Medical Affairs, Member Services, Network Operations, Compliance, Process Improvement, Pharmacy and other critical business units as necessary to drive process change across the organization to improve performance.
• Develop roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Collaboration with analytics team to measure the effectiveness of initiatives and process improvements.
• Coordinate with existing vendors, and/or identify and implement new vendors, in order to drive desired outcomes in quality-based metrics, and risk adjustment activities.
• Lead, coach and instruct process owners and improvement teams in the definition, documentation, measurement, improvement and control of processes aimed at optimizing the quality of the Medicare and ACA programs.
• Create and lead cross-departmental initiatives to change processes to increase the effectiveness of the member experience with the goal of ensuring continued persistence in enrollment and to avoid early disenrollment based on plan dissatisfaction.
• Evaluate the effectiveness of existing operational metrics, developing new metrics as necessary, to better assess the performance of organization in achieving quality, revenue, and satisfaction targets.
• Gather member experience data and conduct analysis to identify gaps, opportunities and performance trends. Utilize information to drive member behavior towards those actions that are expecting to improve health outcomes.
• Track and report on the progress of all Star and Risk initiatives to various levels within the organization to ensure transparent understanding of the opportunities, risks and successes of efforts across the organization.
• Develop a company-wide Star education program that can be easily delivered via digital tools. Support individual units with unit specific training if needed to support key STAR metric understanding.
• Directs the department including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive training and support
• Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.
• Perform other duties as assigned

Skills:

• Expert-level collaboration skills and group facilitation skills with all levels of the organization
• Executive- and Board-level written and oral communication skills to establish and maintain positive relationships with all levels of the organization
• Ability to influence organizational change
• Make decision by processing information quickly and assessing alternatives (often based on incomplete data)
• Documented and proven examples of delivering cost savings at a macro-level
• Demonstrated track record of success, implementing new strategies in a complex environment, with an ability to analyze, assess and respond to enterprise needs with impactful solutions.
• Leadership:
• Demonstrated leadership ability exemplified by; capacity to think strategically and implement tactically to consistently deliver results; well-developed skills in diplomacy and collaboration.
• Demonstrates the drive, determination, and perseverance to get things done
• Builds solid relationships in 360 degrees within the Company, as well as with customers, vendors, and other Blue Plans
• Demonstrated ability to develop and lead high performing and collaborative teams.
• Ensures staff have access to development opportunities both educationally and experientially in order to proactively prepare to support developing business expectations
• Innovates new ideas, tools, and approaches related to process evaluation and re-engineering
• Champions change with an eye to the future in order to position the company to be responsive to market pressure

Knowledge:

• Healthcare operations
• Financial acumen
• Process improvement and leading teams to optimize efficiency and productivity
• Planning, organizing and managing major activities/initiatives.
• Change management theory and practical application

Experience:

• A minimum of seven (7) years work experience in progressively increasing leadership roles in a corporate environment, including at least five (5) years of direct management experience
• Experience in quality assurance processes, industrial engineering concepts, or continual improvement
• Demonstrated ability to manage complex, high-profile assignments involving both people and business issues where there are time and budget constraints

Education and Certifications:

• A Bachelor’s Degree is required, or the equivalent in business and/or technical disciplines
• Government Programs (Medicare Advantage/Medicaid/ACA) experience required
• Graduate degree is preferred(e.g. MBA)

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. 

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.