Skip to main content

A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Director, Medicare Stars and Risk Adjustment

Primary Location: Cary, North Carolina
Additional Locations: NC-Cary, NC-Raleigh
Champions a culture committed to excellence in Medicare Star ratings and risk adjusted revenue (RAR) for the MidSouth Medicare market (NC, SC, TN). Identifies and drives an overall local market strategy for quality, cost management and coding/documentation performance improvement.

Fundamental Components:
Responsible for creating and executing strategies and operational tactics that support the achievement of high quality and Star ratings across the MidSouth Medicare Advantage business. Executes on national quality and RAR initiatives at the local level. Conducts data analysis, in conjunction with national tools, to identify opportunities that maximize quality and Stars outcomes. Develops processes, work flows and other materials to document the operational and strategic components of initiatives. Leads cross functional workgroups 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. Manages local quality programs and vendors. Ensures successful results in medical record retrieval projects, prospective coding programs, provider education initiatives and dissemination of coding best practices. Coordinates with Engagement Managers and RN program managers in performance management of quality, coding and Star Rating measures in Medicare value based contracts. Engages with clinical team and providers as needed serving as subject matter expert on Star rating measures. Investigates operational issues and works with business partners to implement solutions. Influences change in order to improve performance results, organization effectiveness and/or systems/quality/services. Monitors and trends member complaints, grievances and appeals in the local market and creates local activities to mitigate issues. Produces content for training tools for external partners (e.g. brokers, providers) developed around market needs (CTM drivers, trends).

10+ 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.
Demonstrated experience successfully implementing 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
Demonstrated 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 presenting to Senior Leadership

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

Project Management/Project Management Professional (PMP) is desired
Medical Management/Certified Coding Specialist is desired

Functional - Quality Management//7-10 Years
Functional - Medical Management/Medical Management - Medical Economics/4-6 Years
Functional - Project Management/Project Leader/7-10 Years
Functional - Management/Management - Medicare/7-10 Years

Technical - Desktop Tools//7-10 Years/

General Business/Applying Reasoned Judgment/MASTERY
Leadership/Developing and Executing Strategy/MASTERY
Leadership/Driving Change/MASTERY

Leadership/Engaging and Developing People/MASTERY

Telework Specifications:
Option for Part-Time Telework (ex: 2 days office-based, 3 days telework) will be evaluated after a certain period of employment.

This role will be part of a high performing Medicare group that is continuing to grow. In this newly created role, the individual will be empowered to take it to new heights, creating both the opportunity for visibility and growth within the organization, and the ability to meet significant quality/financial goals for the organization.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Potential Telework Position:

Percent of Travel Required:
0 - 10%

Click To Review Our Benefits (PDF)


Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.