Manager, Risk Adjustment and Quality Operations

Huntington Beach Office - Huntington Beach, CA 92647

• Salary Range: $100,000.00 - $125,000.00 Salary
• Position Type: Full Time

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Huntington Beach Office.

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

The Manager, Risk Adjustment & Quality Operations is responsible for driving execution of Medicare Stars, Risk Adjustment (RAF), HEDIS, and CAHPS programs through strong operational leadership and provider partnership. This role focuses on building effective relationships with providers, IPAs/MSOs, and internal teams to improve performance across quality, coding accuracy, and member experience.

This position serves as an operational manager responsible for ensuring that initiatives are implemented effectively, workflows areoptimized, and teams are aligned to achieve organizational goals. The role emphasizes accountability,coordination, and hands-on execution to deliver measurable improvement in Stars and Risk Adjustment outcomes.

Function and Job Responsibilities

Program Management & Execution

• Manage the day-to-day execution of Stars, Risk Adjustment, HEDIS, and CAHPS initiatives
• Ensure operational plans are implemented effectively, on time, and aligned with organizational priorities
• Coordinate cross-functional activities to support chart retrieval, coding programs, outreach, and quality improvement efforts
• Monitor progress of initiatives and ensure timely resolution of operational barriers
• Drive consistency and standardization of workflows across teams and vendors

Provider Engagement & Relationship Management

• Build and maintain strong, collaborative relationships with IPAs, MSOs, PCPs, and provider groups
• Serve as a key liaison between the health plan and providers to drive performance improvement efforts
• Support Provider Relations teams with performance discussions, issue resolution, and escalation management
• Facilitate provider meetings and working sessions focused on closing care gaps, improving access, and enhancing coding practices
• Deliver clear, consistent messaging to providers on expectations, program requirements, and performance goals
• Foster a culture of accountability and partnership with provider organizations

Provider Performance improvement

• Support implementation of provider performance improvement plans across HEDIS, CAHPS, and Risk Adjustment
• Assist providers in improving clinical documentation, coding accuracy, and quality measure performance
• Identify operational opportunities to improve workflow efficiency at the provider level (e.g., chart access, scheduling, outreach)
• Partner with IPAs/MSOs to ensure execution of agreed-upon action plans

Quality, Compliance & Audit Support

• Support operational readiness for HEDIS submissions, NCQA audits, and regulatory activities
• Coordinate with internal teams and providers to ensure timely completion of audit requirements and documentation
• Oversee coding audits, RADV readiness activities, and medical record reviews
• Help ensure providers and vendors are adhering to coding guidelines and regulatory requirements
• Track audit findings and support implementation of corrective actions

Vendor & Program Management

• Coordinate day-to-day operations of vendors supporting chart retrieval, coding, outreach, and abstraction
• Ensure vendors meet established timelines, service expectations, and deliverables
• Coordinate between vendors and internal teams to ensure smooth program execution
• Address operational issues quickly to minimize disruption to program performance

Operational Performance & Continuous Improvement

• Track progress of key initiatives and ensure completion of operational milestones
• Identify and implement process improvements to enhance efficiency and reduce gaps in execution
• Participate in workgroups focused on improving care transitions, medication adherence, access, and coding workflows
• Support development of practical solutions to improve day-to-day operations

Team Management & Development

• Provide day-to-day direction, coaching, and support to assigned team members to ensure strong execution and collaboration
• Foster a team culture that emphasizes accountability, responsiveness, and teamwork
• Conduct regular check-ins to address challenges and keep initiatives on track
• Support team development with a focus on operational excellence and provider engagement skills

Internal & External Collaboration

• Collaborate closely with Provider Relations, Care Management, Pharmacy, Compliance, and IT
• Ensure alignment across teams to support seamless program implementation
• Participate in provider meetings, joint operations meetings, and engagement activities
• Support coordination of member-facing and provider-facing initiatives

Qualifications

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining and sharing exciting possibilities
• Enlist others in a common vision by appealing to shared ambitions

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community
  

Qualifications

Education and Experience

• Bachelor's degree in Healthcare, Business, or related field required (Master’s preferred)
• Minimum of three (3) years of experience in Medicare Advantage, Risk Adjustment, Stars, or Quality programs
• Strong experience in program execution, provider engagement, and operational management
• Experience working directly with IPAs, MSOs, and provider networks
• Experience in educating/training providers and office staff will be a plus.

Licenses/Certifications

• Current Coding Certification in one or more of the following: CPC, CPC-H, CPC-P, CCS, CCS-P, CCA will be a definite plus.

Skills

• Strong knowledge of Medicare Stars, HEDIS, CAHPS, Risk Adjustment (HCC), and coding practices
• Proven ability to build relationships and influence provider behavior
• Excellent communication, presentation, and interpersonal skills
• Strong organizational and project execution skills
• Ability to manage multiple initiatives and priorities in a fast-paced environment
• Strong problem-solving and operational troubleshooting capabilities
• Ability to coordinate cross-functional teams and drive accountability
• Ability to manage multiple priorities in a fast-paced environment

Wage Range: $100,000/year - $125,000/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.