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CVS Health Director, Medicare Risk Adjustment and Star Rating in St Louis, Missouri

Job Description

Leadership position that champions a culture committed to excellence in Medicare Risk Adjustment and Star ratings for Aetna's Heartlands/Midlands Market!! (IA, NE, SD, ND, CO, KS, MO, AR, S. IL) Identifies and drives an overall local market strategy for quality, cost management and coding/documentation performance improvement.

Fundamental Components

Coordinate, lead, and run multiple functional areas/units including full accountability for business/financial results within the local market.

Collaborates with national Medicare Risk Adjustment and Stars teams to execute on critical initiatives.

Responsible for identifying and executing strategies and operational tactics that support the achievement of high quality and Star ratings across the Heartland/Midlands market.

Conducts data analysis, in conjunction with national tools, to find opportunities that maximize quality and Stars outcomes.

Develops processes, work flows and other materials to document the operational and strategic components of initiatives.

Leads team of coding educators.

Leads cross functional work groups and partners with local and enterprise colleagues on Network, Clinical and Quality teams.

Leverages analytical data to identify and prioritize provider outreach strategies for Stars projects, coding education and Risk Adjustment initiatives.

Ensures successful results in medical record retrieval projects, prospective coding programs, provider education initiatives and dissemination of coding standard methodologies.

Coordinates with Provider Engagement Managers and RN program managers in performance management of quality, coding and Stars Ratings in Medicare value based contracts.

Engages with clinical team and providers as needed serving as an SME on Star rating measures.

Investigates operational issues and works with business partners to implement solutions.

Inspire change in order to improve performance results, organization efficiency and/or systems/quality/services.

Monitors and trends member complaints, grievances and appeals in the market and builds local activities to mitigate issues.

Produces content for training tools for external partners (e.g. brokers, providers) developed around market needs (CTM drivers, trends).

Background Experience

  • 5+ years experience with Medicare star ratings, quality, coding and risk adjusted revenue

  • Demonstrated leadership with project management, business process consulting, financial strategic analysis, strategic business planning, and/or risk management consulting.

  • Experience with enterprise-wide and/or cross-functional large scale initiatives with high degree of complexity.

  • Proven experience successfully executing change in complex organizations.

  • Strong analytical skills, with the ability to review and manipulate data to draw conclusions

  • Ability to think strategically and to translate strategy into measurable goals

  • Proven relationship management skills at the senior level; capacity to quickly build and maintain credible relationships at varying levels of the organization simultaneously. Communication and presentation skills; experience addressing Senior Leadership

Additional Job Information

Exceptional communications skills including ability to interact with a variety of external and internal audiences including senior management.


Bachelor's degree or equivalent experience

Percent of Travel Required

10 - 25%

Business Overview

Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.