About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose: 

The Medicare 5-Star Analyst is responsible for supporting Fallon Health's Medicare Star Ratings improvement strategy through advanced analytics, performance monitoring, reporting, forecasting, and operational consultation. This role serves as the organization's primary analytical resource for Medicare Star performance and works closely with Fallon Health's Stars analytics vendor, Hyperlift, to monitor performance projections, validate measure forecasts, identify improvement opportunities, and support strategic decision making. The Analyst serves as a subject matter expert on CMS Star Ratings, CAHPS, HOS, HEDIS, and related quality measures. Working closely with organizational leaders, business owners, and measure stewards, this position develops performance dashboards and exhibits, conducts trend analyses, identifies risks and opportunities, and provides actionable recommendations to improve Medicare Star performance. The Medicare 5-Star Analyst leverages data from trending and star results to help evaluate operational performance, monitor key performance indicators, quantify intervention effectiveness, and support enterprise-wide quality improvement initiatives. The role is responsible for translating complex data into meaningful business insights that drive informed decision-making and support Fallon Health's Medicare performance goals.

Primary Job Responsibilities

Medicare 5-Star Performance Management

• Serve as the primary analytical resource supporting Fallon Health's Medicare Star Ratings strategy.
• Monitor and evaluate performance across all CMS Star measures.
• Develop and maintain internal dashboards, exhibits and surveillance reports.
• Identify emerging performance risks, opportunities, and trends affecting Star Ratings outcomes.
• Track measure-level interventions and assess effectiveness of improvement activities.
• Partner with business owners and department leaders to establish accountability and performance monitoring processes.
• Support annual Stars planning, goal setting, and performance reviews.
• Identify cultural trends, demographic patterns, disparities, and social determinants of health that may affect Medicare Star performance.
• Analyze provider practice patterns to identify performance variation, barriers, and improvement opportunities.
• Identify and define key performance indicators (KPIs), establish accountability tracking, and lead routine performance reviews.
• Manage and actively participate in meetings across all Medicare 5-Star domains, including agenda development, performance review, action tracking, and follow-up.

Star Strategy & Vendor Management

• Serve as the primary liaison between Fallon Health and Hyperlift for Medicare Stars analytics and reporting activities.
• Collaborate with Hyperlift to develop, validate, and interpret Star Ratings projections and forecast models.
• Monitor monthly and annual performance forecasts to identify potential risks and opportunities impacting Star outcomes.
• Evaluate projected measure performance and recommend intervention strategies to improve ratings.
• Validate vendor reporting outputs and reconcile forecasts with internal reporting and operational data.
• Partner with business owners and leadership to translate forecast results into actionable improvement plans.
• Support annual Stars goal setting, strategic planning, and performance review activities.
• Participate in vendor meetings and oversee follow-up activities to ensure achievement of organizational objectives.

Reporting and Data Analytics

• Design, develop, maintain, and enhance operational and regulatory reports.
• Analyze large healthcare datasets to identify trends, patterns, and root causes.
• Create ad hoc analyses and executive presentations to support organizational decision-making.
• Validate data integrity and reconcile reporting outputs across multiple systems.
• Develop measures, KPIs, and analytical frameworks to evaluate business performance.
• Support predictive and trend analysis to identify future performance impacts.
• Partner with technical resources to define requirements and develop accurate, actionable reporting and analytical outputs.
• Develop alternative methods to obtain or approximate unavailable data, with appropriate validation, documentation, and disclosure of limitations.

Business Consultation and Process Improvement

• Collaborate with business owners to identify opportunities for operational improvement.
• Translate analytical findings into actionable business recommendations.
• Participate in root cause investigations and corrective action planning.
• Support process improvement initiatives related to Star measures and quality performance.
• Provide analytical consultation for cross-functional projects impacting Medicare quality outcomes.
• Identify reporting efficiencies and automation opportunities
• Conduct thorough end-to-end reviews of processes supporting all Medicare Star measures to identify gaps, dependencies, control weaknesses, and improvement opportunities.

Special Projects and Strategic Initiatives

• Participate in enterprise projects supporting Medicare, quality, compliance, and operational objectives.
• Assist leadership with strategic planning and performance improvement initiatives.
• Support implementation and testing of new reporting solutions and analytical tools.

Perform additional duties as assigned.

Experience

Regulatory and Healthcare Knowledge

• Knowledge of Medicare Star Ratings methodology and performance measurement.
• Understanding of HEDIS, CAHPS, HOS, and CMS quality programs.
• Knowledge of healthcare operations, claims, enrollment, provider, and quality data.
• Understanding of performance measurement, KPI development, and benchmarking methodologies.

Analytical Skills

• Advanced analytical and critical thinking skills.
• Ability to identify patterns, trends, risks, and opportunities within complex datasets.
• Strong problem-solving and root-cause analysis capabilities.
• Ability to develop forecasts and performance projections.

Technology Skills

• Advanced Microsoft Excel skills.
• Experience with SQL and data extraction tools.
• Experience developing dashboards and visualization tools.
• Proficiency with Microsoft Office Suite.
• Experience with healthcare reporting platforms preferred.

Communication Skills

• Ability to communicate complex technical information to non-technical audiences.
• Strong written and verbal communication skills.
• Ability to present findings to leadership and business stakeholders.
• Strong facilitation and collaboration skills.
• Demonstrated ability to independently identify, assess, and resolve complex problems; proactive self-starter with sound judgment and appropriate escalation practices.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.