Healthcare Quality and Risk Advisor

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

Quality/Risk Advisor is responsible for establishing and maintaining positive working relationships with Management Service Organizations (MSOs) Independent Physician Associations(IPAs) and Provider Partners by managing and providing on ongoing education/ support related to Managed Care performance expectations related to HEDIS/Stars, CAHPS, Risk Adjustment and other Quality/Risk related Key Performance Indicators(KPIs) and State/Federal regulatory requirements. The Advisor will ensure that the providers have the tools, resources and support to meet the needs and performance expectations of Clever Care’s members. The Advisor will work with cross-functional teams  internal to Clever Care and external including Clever Care’s provider network and vendors to collaborate on Quality Initiatives, Action Planning, Data Reconciliation, Medical Record Reviews and Education/Trainings.

Functions & Job Responsibilities

• Establish and maintain positive working relationships od MSO/IPA and Providers
• Quality/Risk Performance Oversight to include meetings, presentation, development of tools, resources and support to ensure MSO/IPAs and providers meet key performance indicators
• Educate MSO/IPAs and providers on NCQA HEDIS measures and regulatory requirements, risk adjustment, coding best practice, CAHPS
• Collect, summarize and trend provider data for HEDIS/Risk to develop performance improvement plans
• Support HEDIS chart collections, abstractions and summary of findings for provider education
• Participate in external and internal cross-functional workgroups to establish and monitor  QI/Risk KPIs, Quality Initiatives, Barrier Analysis and Annual Workplan Reviews and Evaluations
• Actively participate in Member Experience Initiative including Member Experience Workgroup, Member Advisory Committee and Member Appreciation Events
• Work closely with Provider Relations and Community Center representatives on Quality/Risk and Member Experience related tasks
• Partner with Pharmacy team on MSO/IPA and Provider Medication Adherence Performance Initiatives/Strategies
• May be required to support Member/Provider outreach as needed for Quality/Risk related activities
• Must be comfortable leading and conducting MSO/IPA and Provider Meetings in-person and/or via team’s meetings
• Meet with assigned MSO/IPA and Providers at minimum monthly for performance management, oversight and QI strategies. Will need be comfortable creating an agenda, PowerPoint presentation and effectively drive the meeting keeping the provider/IPA engaged and accountable to deliver results. Timely distribution of meeting notes and oversight of action items through completion.

Qualifications

Education and Experience

• Bachelors Degree or 4+ years of work related experience in a similar position required
• 2 years of managed care experience required
• 2 years of HEDIS/Risk training or education experience preferred

Skills

• Managed Care Experience is a plus
• Effectively manage and foster positive working relationships
• Leads by example and models the way
• Highly motivated to deliver results
• Microsoft Suite including  expertise in Excel, Powerpoint, Access etc.
• Effective communications skills
• Knowledge of HEDIS/Risk  regulatory requirements
• Experience with HEDIS Hybrid  Project including
• Knowledgeable in HEDIS/Risk documentation and coding guidelines
• Expertise in data reconciliation, root cause analysis and barrier analysis
• Accountable and driven to exceed expectations

Wage Range: $65,000/year to $85,000/year

Physical & Working Environment

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

#LI-Hybrid