Senior Business Process Advisor, RA and Quality

Job Details:

Job Location:

Huntington Beach Office - Huntington Beach, CA 92647, Position Type:
Full Time, Salary Range: $91,000.00 - $ Salary, 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.

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.

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.

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.

• 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.

• 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.

• 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.

• Partner with Analytics teams to support…