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The Program Manager, Risk Adjustment & Stars, serves as the connective link between Alpine's technical teams (coding, data, analytics, IT) and its operational and business stakeholders (leadership, quality, health plan operations) for risk adjustment and Star Ratings performance. This role translates technical details, such as data pipelines, coding logic, and CMS methodology, into operational plans, priorities, and decisions, while ensuring operational requirements and business goals are reflected back into the technical work. The role does not require direct provider-facing engagement.
Program Management
- Owns the annual risk adjustment and Stars improvement program cycle, coordinating between technical teams and operational/business stakeholders across prospective and retrospective programs, visit-based campaigns, and gap closure workflows.
- Builds and manages program timelines and throughput; reports progress to Alpine leadership and health plan partners in clear, business-friendly terms.
- Leads cross-functional workgroups spanning coding/HCC teams, clinical quality, IT, and analytics, ensuring technical work stays aligned to operational priorities.
- Manages program-level documentation and requirements, translating between technical specifications and operational plans.
Risk Adjustment
- Acts as the liaison between coding/data teams and operational stakeholders on HCC capture workflows, chart review pipelines, and gap identification, ensuring both sides understand priorities and constraints.
- Manages relationships with vendors, coordinating technical file exchange and integration needs with operational timelines and expectations.
- Monitors RAF score trends and performance results, working with analytics teams to interpret findings and translates them into operational action plans.
- Coordinates risk adjustment data submission accuracy and reconciliation (EDS), connecting technical issue resolution with business and health plan deadlines.
- Tracks HCC model version transitions (e.g., CMS-HCC V24/V28) and communicates their operational and financial impact to leadership and business teams.
Stars & Quality
- Coordinates Alpine's Star Ratings strategy across HEDIS, CAHPS, HOS, and medication adherence measures, connecting technical measure logic with operational execution.
- Partners with analytics teams to maintain measure-level performance tracking and cut-point modeling, translating results into operational priorities and gap closure plans.
- Serves as point of contact for Alpine with health plan Stars/quality teams, bridging technical data exchange requirements with operational and contractual needs.
Analytics & Reporting
- Partners with analytics and data teams to define KPIs and dashboards for RAF accuracy, coding gap closure rates, and Star measure performance, ensuring outputs are operationally useful.
- Translates CMS methodology updates (HCC model version changes, Star Ratings technical notes, measure weighting changes) for both technical teams (as specifications) and operational teams (as business impact).
- Helps identify and escalate data integrity issues across source systems (claims, EHR, supplemental data feeds), coordinating resolution between technical and operational owners.
- Presents performance results and program recommendations to Alpine executive leadership and payer partners.
Compliance & Governance
- Ensures all program activities comply with CMS regulations, ICD-10-CM coding guidelines, and Alpine's compliance policies.
- Supports RADV audit readiness and health plan data validation requests, coordinating between technical teams pulling data and operational/compliance teams managing the response.
Bachelor's degree in health informatics, data analytics, healthcare administration, business, or related field (Master's preferred).
Five (5) to seven (7) years of experience in Medicare Advantage risk adjustment and/or Star Ratings/quality improvement, ideally within a value-based care (VBC) setting.
Preferred Qualifications
- Certified Risk Adjustment Coder (CRC) credential.
- Experience with value-based care, ACOs, or delegated risk arrangements.
- Familiarity with multiple health plan Stars/quality programs and data exchange requirements.
- PMP or similar certification.
- KNOWLEDGE, SKILLS, ABILITIES:
- Working knowledge of CMS HCC risk adjustment models, RAF score methodology, EDS submission processes, and Star Ratings measure specifications.
- Demonstrated ability to work effectively with both technical teams (data, analytics, IT) and operational/business stakeholders, translating between the two.
- Proven program/project management experience managing cross-functional initiatives involving both technical and operational workstreams.
- Working proficiency in Excel required; familiarity with SQL, Tableau, Power BI, or similar tools a plus.
- Strong written and verbal communication skills, with the ability to translate technical and regulatory detail for operational and executive audiences.
- Skilled at translating between technical and operational audiences, comfortable in both worlds without needing to be a deep technical expert.
- Strong relationship management and cross-functional collaboration skills.
- Analytical and detail-oriented, able to interpret data and technical findings and turn them into operational plans.
- Adaptable to evolving CMS methodology and health plan requirements.- Able to travel to meetings
- Ability to handle multiple demands concurrently in a high stress environment; organize, coordinate, set priorities and meet deadlines
- Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures
