Accountabilities:

Lead and oversee Risk Adjustment (BOI), Quality (HEDIS), and Cost of Care operational programs across at least three markets, ensuring consistent execution and alignment with organizational objectives.
Develop, implement, and maintain standard operating procedures (SOPs), service-level agreements (SLAs), and responsibility frameworks (RACI) to support effective program delivery.
Collaborate with Central Operations to manage and optimize pre-visit medical record reviews, post-visit coding reviews, medical chart collection, query workflows, and provider engagement processes.
Partner with Market Leaders and local operations teams to monitor performance, identify operational challenges, and implement corrective actions and improvement plans.
Define and monitor key performance indicators (KPIs), conduct root cause analyses, and lead continuous improvement initiatives to standardize best practices across markets.
Act as the primary escalation point for operational challenges, coordinating cross-functional teams to resolve issues and ensure readiness for new initiatives.
Oversee operational budgets for Risk Adjustment and Quality programs, including staffing, contractors, and vendor expenditures, while identifying opportunities to optimize costs and resource utilization.
Partner with Data & Analytics and IT/Engineering teams to define technical requirements, data pipelines, electronic medical record (EMR) integrations, claims integrations, and reporting dashboards.
Collaborate with technology teams to evaluate, test, and implement automation solutions that reduce manual workloads, improve accuracy, and increase operational scalability.
Lead regional capacity planning, workforce modeling, recruitment, onboarding, training, and performance management in collaboration with regional leadership.
Build strong relationships with healthcare providers, vendor partners, and internal stakeholders to support effective program execution and operational alignment.
Travel approximately 4–10 days per month to visit partner medical groups, support regional operations, and strengthen stakeholder relationships.

Requirements

Bachelor's degree in Business Administration, Healthcare Management, Public Health, or a related field. An advanced degree is preferred.
At least 5 years of professional experience in healthcare operations, including a minimum of 3 years leading multi-market Risk Adjustment or Quality programs.
Strong understanding of HEDIS quality measures, risk adjustment coding methodologies, and healthcare data systems, including claims and electronic medical records (EMR).
Demonstrated experience managing operational teams, coordinating vendor relationships, and overseeing complex healthcare programs across multiple locations.
Proven program and project management capabilities, with experience developing operational strategies, managing competing priorities, and delivering measurable results.
Strong knowledge of process improvement methodologies, including the ability to identify inefficiencies, conduct root cause analyses, and implement sustainable operational improvements.
Analytical proficiency, including experience working with dashboards, KPIs, and performance reporting, as well as SQL knowledge or the ability to collaborate effectively with analytics teams.
Experience with workforce planning, staffing models, budget oversight, resource allocation, and operational performance management.
Strong understanding of healthcare technology environments, including EMR systems, claims data, reporting tools, and technology-enabled workflows.
Excellent written and verbal communication skills, with the ability to engage effectively with senior leadership, healthcare providers, vendors, and cross-functional teams.
Strong mathematical and analytical reasoning skills, including the ability to interpret percentages, ratios, statistical concepts, and performance data to support business decisions.
Excellent problem-solving abilities, with the capacity to apply logical and structured thinking to complex operational challenges.

How Jobgether works

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

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