Senior Business Process Advisor, RA and Quality

Huntington Beach Office - Huntington Beach, CA 92647

• Salary Range: $91,000.00 - $100,000.00 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 Senior Business Process Advisor, Quality & Risk Adjustment, serves as the primary business and operational liaison between Risk Adjustment, Quality/Stars, Clinical Operations, Provider Relations, Analytics, and Information Technology. This role is responsible for translating business priorities, CMS regulatory requirements, and operational needs into scalable workflows, reporting solutions, and technology enhancements that improve Medicare Advantage performance.

The Senior Business Process Advisor leads requirements gathering, business process analysis, system implementation support, user acceptance testing (UAT), reporting validation, and performance analytics across Medicare Stars, HEDIS, CAHPS, Risk Adjustment, Population Health, and provider performance initiatives. This position plays a critical role in ensuring organizational priorities are effectively implemented through data-driven solutions, accurate reporting, and cross-functional collaboration.

The role combines business analysis, operational problem-solving, data validation, project coordination, and continuous improvement to support organizational goals related to quality outcomes, member experience, risk score accuracy, regulatory compliance, and financial performance.

Functions & Responsibilities

Business Analysis & Requirements Management

· Partner with business stakeholders to understand operational challenges, strategic priorities, and reporting needs.

· Facilitate requirements gathering sessions with Quality, Risk Adjustment, Clinical Operations, Provider Relations, Analytics, and IT teams.

· Translate business objectives into detailed functional and technical requirements.

· Create business requirements documents, process flows, use cases, user stories, data dictionaries, and testing plans.

· Evaluate existing workflows and identify opportunities for automation, standardization, and operational improvement.

· Ensure business requirements remain aligned with CMS, NCQA, HEDIS, Stars, CAHPS, and CMS Risk Adjustment requirements.

Stars, HEDIS & CAHPS Programs

· Support implementation and enhancement of Medicare Stars, HEDIS, and CAHPS programs through business analysis and reporting solutions.

· Analyze measure specifications and CMS technical guidance to ensure accurate operational interpretation and implementation.

· Partner with operational teams to develop and maintain gap closure reporting and provider performance dashboards.

· Validate quality measure logic and reporting outputs to ensure consistency and accuracy.

· Support annual Stars, HEDIS, and CAHPS program readiness activities.

· Assist with development of interventions designed to improve member outcomes and Star Ratings performance.

Risk Adjustment & RAF Optimization

· Support expansion and enhancement of Risk Adjustment programs across prospective, retrospective, and concurrent initiatives.

· Analyze HCC, RAF, coding, suspecting, recapture, and provider performance data.

· Translate CMS Risk Adjustment guidance into actionable business requirements and operational workflows.

· Collaborate with coding, analytics, provider engagement, and IT teams to improve data capture and reporting capabilities.

· Validate risk adjustment reporting, encounter data, coding outputs, and provider scorecards.

· Support RADV readiness initiatives, coding validation projects, and documentation improvement efforts.

Population Health Analytics & Predictive Modeling

· Partner with Analytics teams to support implementation and optimization of population health and predictive modeling programs.

· Support implementation and operational use of Johns Hopkins ACG and other population health stratification tools.

· Analyze population health trends, disease burden, risk stratification, utilization patterns, and intervention opportunities.

· Translate predictive analytics outputs into actionable business recommendations.

· Identify opportunities to improve outreach effectiveness, care gap closure, member engagement, and clinical outcomes.

Provider Performance Analytics & Reporting

· Develop and maintain provider performance reporting requirements for IPAs, medical groups, and PCPs.

· Support development of provider scorecards related to Stars, HEDIS, CAHPS, Risk Adjustment, utilization, and performance incentives.

· Validate reporting logic and performance calculations before deployment.

· Partner with Provider Relations and operational teams to identify improvement opportunities.

· Analyze provider-level performance trends and support targeted intervention planning.

System Implementation & Testing

· Lead User Acceptance Testing (UAT) efforts for new applications, reports, dashboards, workflows, and system enhancements.

· Develop test plans, testing scenarios, acceptance criteria, and issue logs.

· Coordinate testing activities among business stakeholders and technology partners.

· Validate data integrity, reporting outputs, and workflow functionality.

· Monitor defects, prioritize issues, and coordinate resolution activities.

· Support implementation of Salesforce, Cozeva, population health, analytics, and other operational technology solutions.

Regulatory & Compliance Support

· Interpret CMS, NCQA, HEDIS, Stars, CAHPS, and Risk Adjustment guidance and translate requirements into operational specifications.

· Support audit readiness activities, including HEDIS audits, RADV audits, and regulatory reviews.

· Ensure reporting and operational processes align with applicable compliance requirements.

· Participate in analysis and remediation of audit findings and corrective action plans.

Project Coordination & Cross-Functional Collaboration

· Support cross-functional initiatives from concept through implementation.

· Facilitate project meetings, document action items, and monitor deliverables.

· Coordinate across business units to ensure successful implementation of operational priorities.

· Escalate risks, dependencies, and barriers that may impact project success.

· Promote collaboration and alignment among operational, clinical, analytical, and technology teams.

Qualifications

Qualifications

Education and Experience

· Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Information Systems, Data Analytics, or related field.

· Minimum five (5) years of experience in healthcare business analysis, healthcare operations, managed care, Medicare Advantage, or health plan analytics.

· Minimum three (3) years of experience supporting Medicare Stars, HEDIS, CAHPS, Risk Adjustment, Population Health, or related programs.

· Experience working directly with cross-functional business and technology teams.

· Health plan experience strongly preferred.

· Medicare Advantage experience strongly preferred.

Skills & Competencies

· Medicare Stars and HEDIS reporting and operational support.

· Risk Adjustment (HCC/RAF) analytics and reporting.

· Provider performance reporting and scorecard development.

· Predictive modeling and healthcare analytics.

· CMS regulatory interpretation and operational implementation.

· Salesforce administration or reporting environments.

· Vendor implementation and testing activities.

· Advanced SQL skills.

· Strong analytical and problem-solving capabilities.

· Experience with Power BI, Tableau, Salesforce, or similar business intelligence platforms.

· Experience validating reporting logic, measure calculations, and data integrity.

· Strong User Acceptance Testing (UAT) leadership and execution skills.

· Process mapping and workflow documentation expertise.

· Ability to interpret and translate regulatory requirements into technical specifications.

· Strong Microsoft Excel skills, including data analysis and reporting.

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.