Director Risk Adjustment Program

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Job description

Position Description:
Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."

The Risk Adjustment Program Director is responsible of the oversight of Capital's Medicare and ACA Risk Adjustment Program strategy and operations to ensure regulatory compliance, accurate chronic conditions documentation and appropriate care coordination. This role provides strategic and tactical direction of the Program in collaboration with the Stars & Risk Adjustment Sr. Director. Function as a Risk Adjustment subject matter expert and business owner of risk adjustment processes ensuring efficacy, accuracy and compliance with Program that is organized in the following functional areas: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Program pillars.

Responsibilities and Qualifications:
Actively monitor performance, productivity, and staff development activities.

Lead and oversight Risk Adjustment functional areas driving optimal outcomes: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Programs.

Guide and oversees the creation, implementation, and monitoring process of the Risk Adjustment Program strategy, objectives, tactics, and initiatives to drive a year over year quality of care improvements, appropriate reimbursement, and compliance with CMS mandates, regulations, and audits.

Lead oversight of Risk Adjustment vendors. Lead in the identification, evaluation, and management of risk adjustment vendors. RFPs readiness, potential vendors evaluation, selection, project implementation, etc. Support Vendor Alliance negotiations activities. Support the execution of MSAs, BAAs, contracts, and SOWs with clear compliance and service level agreements.

Acts as subject matter expert, maintain up-to date knowledge and interpret applicable federal and state regulations, CMS guidelines and requirements, and Medicare and ACA models transferring knowledge to leadership and cross-functional teams, etc. Implement a governance structure that provides significant oversight and audit readiness. Build statistically sound strategies to evaluate, monitor compliance, and educate senior management of any potential risk and implement appropriate remediation activities. Collaborate with the Government Program Compliance Officer to develop, execute and continually refine a quality assurance program to monitor, audit and improve the CBC Risk Adjustment Program. Develop and implement remediation strategies as needed with individual providers, provider groups, internal teams, etc.

Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies. Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals.

Ensure the coordination of processes, protocols and data flow between risk adjustment and cross-functional teams like care management, HEDIS, etc. resulting in appropriate follow of care and quality of care improvement's activities.

Lead the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability.

Lead, develop, and mentor the Risk Adjustment team.

Other duties as assigned or requested.

Skills:

Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand. Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach. Ability to influence and persuade people to collaborate and execute toward a common goal.

Successful record of managing people and multiple projects with excellent results, meeting desired outcomes and goals. Eager to work with sense of urgency aligned with priorities, overcome obstacles, if needed seek for support early driving the best results to positive impact the Company and team goals.

Ability to think analytically to resolve issues; solution-focused mindset; creative, innovative, and compliance thinker.

Proven leadership experience in an agile and dynamic work environment. Able to connect and influence direct reports and/or team members across the organization driving collaboration /teamwork.

Knowledge:

Comprehensive knowledge of Medicare and ACA programs.

Detailed knowledge of the Medicare and ACA Risk Revenue programs

Extensive analytical and financial knowledge.

In-depth understanding of key applicable federal, state, local and international legislation, ability to develop and/or interpret complex regulatory or legal documents and ability to communicate technical and complex concepts.

Ability to prioritized tasks and shift readily between "big picture" and small-but-critical details. Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions.

Advance proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Project Management tools, Teams/WebEx/ZOOM.

Mastery of CMS HCC Risk Adjustment coding and data validation requirements.

Advance understanding of the Medicare and ACA Risk Adjustment models and regulations/enforcements.

Strategic mindset, action and results oriented keeping the department/units moving forward by making good and timely decisions meeting goals and objectives.

Strong financial acumen by using financial analysis to develop, evaluate, and/or act on strategic opportunities.

Experience:

7 years' experience working with Medicare Advantage Plans experience.

5 years' experience overseeing and leading Risk Adjustment Program.

3 years' experience building and leading efficient operations and successful teams.

5 years of management experience highly preferred.

3 years' experience of budget administration.

Education and Certifications:

Bachelor's degree in business administration, Health Management/Administration, Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics, Public Health or Health-related Sciences; or additional 4 years of relevant experience in lieu of degree.

Certified Risk Adjustment Coder Certification is preferred.

Location:

This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.

The employee must be able to work over 40 hours per week.

The employee must occasionally lift and/or move up to 5 pounds.

About Us:
We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.
And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.

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