Quality and Risk Performance Officer, Medicare Advantage

About the Company

BlueCross BlueShield of South Carolina has been a cornerstone of the national healthcare landscape for over seven decades, with deep roots in the South Carolina community. As the largest insurance company in the state, we are also one of the nation's leading administrators of government contracts, operate one of the Southeast's most sophisticated data processing centers, and maintain a diverse family of subsidiary companies. Our commitment to outstanding service and innovation makes us a leader in the industry.

About the Role

As the Medicare Advantage Quality and Risk Performance Officer, you will collaborate closely with the leadership team to oversee all activities related to Star rating improvement. This role requires an innovative thought leader who can diagnose performance gaps, define organizational strategy, and craft both annual and long-term improvement plans. You will use tactical execution to analyze data, track trends, and develop solutions for Stars rating initiatives while clearly communicating challenges, solutions, and results to executives.

In addition to Stars expertise, this role seeks a results-driven professional with experience in Medicare Advantage risk adjustment and value-based healthcare programs. You will support performance optimization and revenue integrity through a strong understanding of HCC coding, RAF score optimization, and CMS regulatory requirements. The ideal candidate will translate data insights into actionable strategies, lead risk adjustment initiatives, ensure audit readiness (e.g., RADV), and identify opportunities to enhance coding capture and care gap closure. Experience with value-based arrangements, including shared savings models and provider incentive programs, is highly preferred.

This is an essential leadership role for individuals who thrive in complex, highly regulated environments and are passionate about fostering team morale, inspiring collaboration, and driving strategic outcomes.

Responsibilities

• Develop and implement strategic plans to improve the Stars ratings for Medicare Advantage programs.
• Ensure continuous evaluation of plans and timely implementation of modifications.
• Lead cross-functional teams to drive Stars rating initiatives and best practices by promoting innovation, strategy development, and implementation excellence.
• Communicate performance progress, new initiatives, organizational barriers, and expectations of results to senior leadership.
• Develop reports for senior leaders and internal stakeholders, presenting findings, ongoing performance measures, and recommended action plans.
• Build and maintain effective relationships with providers and vendors, developing strategies to engage, educate, and motivate providers.
• 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 programs.
• Stay abreast of existing and new legislation impacting Stars ratings and keep the organization informed.
• Provide oversight to the Stars team.
• Lead risk adjustment initiatives and support audit readiness (e.g., RADV).
• Identify opportunities to enhance coding capture and care gap closure.

Requirements

• Bachelor's degree (required).
• 10 years of experience in insurance, healthcare, or a similarly complex industry.
• 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.
• Proficiency in Microsoft Office suite, including advanced PowerPoint and Excel skills.

Skills and Abilities

• Ability to effectively lead organization-wide initiatives.
• Ability to develop and lead high-performing teams.
• 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 individual contributors, executives, management, physicians, and vendors.

Preferred Qualifications

• 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.

Location

This is a full-time (40 hours/week), onsite position at our Government Programs Complex located at 17 Technology Circle, Columbia, SC. The schedule is Monday through Friday.

Benefits

• 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.