Director of Risk Adjustment

Baystate Health•Springfield, MA

22h

About The Position

Location: Monarch Place; Springfield MA (MA & CT candidates only) Schedule: Monday-Friday; fulltime; 40hrs. Job Responsibilities: Develops and implements risk adjustment strategy, policies and standard operating procedures Collaborates with physicians, mid-level providers, other personnel, including coding experts, in risk adjustment review of the medical record Serves as Health New England’s ambassador in the Risk Adjustment Community Works with industry on best practices for risk adjustment Manages, measures, and evaluates performance of Health New England’s risk adjustment vendors Manages all data submission requirements Prepares risk adjustment training programs for network physicians, mid-level providers, and plan personnel Ensures that all risk adjustment related activities are compliant with CMS/ACA and state requirements Serves as the risk adjustment compliance point of contact for HNE’s Compliance Department Collaborates with data management personnel in the appropriate formatting and methodology of risk adjustment analysis and related reporting Develops productivity standards for risk adjustment auditing of claims or medical records Collaborates with the Provider Relations Department to provide coding and risk adjustment education and resource information to network providers Conducts educational events as necessary Participates in administrative team’s preparation of Medicare Advantage annual bids risk adjustment determination Maintains expert knowledge of AMA’s Coding systems, including ICD-9 & 10 diagnostic, CPT, HCPCS codes and any national updates or revisions of medical diagnostic, procedural, or medical supply coding In collaboration with Plan management, participates in regulatory review and/or audit of submitted claims risk adjustment coding Develops risk adjustment training materials for network providers, plan personnel and prospective network providers Maintains working knowledge of Plan information management systems Collaborates with the Managed Care Data Systems personnel in the development of reports and/or customized applications utilized for risk adjustment data analysis and reporting Establishes business and functional requirements needed to define technology/systems platform Creates executive level reports and performance metrics to keep Health New England up-to-date on risk adjustment Manages, trains, coaches and develops staff

Requirements

Bachelor’s degree in a related field.
7–10 years of experience in an HMO or MCO with direct HCC risk adjustment experience.
At least 2 years of management experience.
Experience with medical claims review, coding, or utilization management.
Knowledge of CMS risk adjustment methodologies and ICD-9/ICD-10 coding.
Ability to obtain relevant coding or risk adjustment certification within a reasonable timeframe if not already held.

Nice To Haves

Master’s degree in healthcare administration, public health, health informatics, population health, or a related healthcare field.
Professional certification such as Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or similar coding credential.
Experience in population health analytics and risk adjustment strategy.
Experience across multiple lines of business including ACA, Medicare Advantage (MA), and Medicaid models.

Responsibilities

Develops and implements risk adjustment strategy, policies and standard operating procedures
Collaborates with physicians, mid-level providers, other personnel, including coding experts, in risk adjustment review of the medical record
Serves as Health New England’s ambassador in the Risk Adjustment Community
Works with industry on best practices for risk adjustment
Manages, measures, and evaluates performance of Health New England’s risk adjustment vendors
Manages all data submission requirements
Prepares risk adjustment training programs for network physicians, mid-level providers, and plan personnel
Ensures that all risk adjustment related activities are compliant with CMS/ACA and state requirements
Serves as the risk adjustment compliance point of contact for HNE’s Compliance Department
Collaborates with data management personnel in the appropriate formatting and methodology of risk adjustment analysis and related reporting
Develops productivity standards for risk adjustment auditing of claims or medical records
Collaborates with the Provider Relations Department to provide coding and risk adjustment education and resource information to network providers
Conducts educational events as necessary
Participates in administrative team’s preparation of Medicare Advantage annual bids risk adjustment determination
Maintains expert knowledge of AMA’s Coding systems, including ICD-9 & 10 diagnostic, CPT, HCPCS codes and any national updates or revisions of medical diagnostic, procedural, or medical supply coding
In collaboration with Plan management, participates in regulatory review and/or audit of submitted claims risk adjustment coding
Develops risk adjustment training materials for network providers, plan personnel and prospective network providers
Maintains working knowledge of Plan information management systems
Collaborates with the Managed Care Data Systems personnel in the development of reports and/or customized applications utilized for risk adjustment data analysis and reporting
Establishes business and functional requirements needed to define technology/systems platform
Creates executive level reports and performance metrics to keep Health New England up-to-date on risk adjustment
Manages, trains, coaches and develops staff