[Hiring] Medicare Quality & Risk Adjustment Program Lead @Montage Health

Role Description

The Medicare Quality & Risk Adjustment Program Lead/RN is responsible for operational leadership and coordination of Medicare Advantage Quality, HEDIS, Stars, Risk Adjustment, and audit readiness activities. Serves as the primary subject matter expert and operational lead for:

• HEDIS reporting
• Supplemental data collection
• Vendor management
• Provider reporting
• Risk adjustment program execution
• Chart retrieval activities
• RADV readiness
• Performance improvement initiatives

Partners with internal stakeholders, provider organizations, consultants, and vendors to ensure accurate reporting, regulatory compliance, and achievement of organizational quality and risk adjustment goals.

Qualifications

• 2+ years of health plan experience specifically in Medicare Advantage Quality, HEDIS, Stars or Risk Adjustment operations.
• 3+ years of clinical practice experience in acute, ambulatory or managed care setting.
• Demonstrated experience supporting HEDIS reporting, performance monitoring, and quality improvement initiatives.
• Experience working with risk adjustment workflows, chart retrieval, coding vendor coordination, or HCC documentation processes.
• Familiarity with CMS Medicare Advantage regulations, NCQA HEDIS audit processes, and RADV requirements.

Requirements

• 3–5 years of experience in Medicare Advantage quality performance, Stars improvement, or risk adjustment program execution.
• Experience supporting or leading cross-functional initiatives involving Quality, Member Experience, Risk Adjustment, Compliance, and Provider Engagement.
• Experience with project management, workflow optimization, or vendor oversight in a health plan environment.
• Experience working with population health, value-based care programs, or provider performance reporting.

Benefits

• Active, unrestricted Registered Nurse License
• Bachelor’s degree in Nursing, Healthcare Administration, Public Health or related field

Knowledge & Skills

• Strong working knowledge of HEDIS measures, Stars methodology, CAHPS drivers, and CMS quality programs.
• Understanding of risk adjustment models (HCC/RAF), prospective and retrospective coding workflows, and RADV audit processes.
• Ability to interpret and validate clinical, claims, and supplemental data to support accurate reporting and performance improvement.
• Proficiency with quality and risk adjustment vendor platforms, chart retrieval systems, and provider reporting tools.
• Strong analytical skills with the ability to identify trends, validate data, and translate insights into operational action.
• Excellent communication and relationship-building skills with providers, vendors, and internal stakeholders.
• Ability to manage multiple projects, timelines, and deliverables in a fast-paced regulatory environment.
• Demonstrated ability to support a culture of continuous improvement, accountability, and member-centric service.

Certifications

• Preferred: Certified Professional in Healthcare Quality (CPHQ)
• Preferred: Certified Risk Adjustment Coder (CRC) or equivalent

Salary

$128,876 annually

Assigned Work Hours

Full time (exempt) 8am-5pm PST

Position Type

Regular