Director Risk Adjustment Program

Capital Blue Cross•Harrisburg, PA

About The Position

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.

Requirements

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.
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.
Strategic mindset, action and results oriented keeping the department/units moving forward by making good and timely decisions meeting goals and objectives.
Advance understanding of the Medicare and ACA Risk Adjustment models and regulations/enforcements.
Strong financial acumen by using financial analysis to develop, evaluate, and/or act on strategic opportunities.
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.
3 years' experience of budget administration.
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.
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.

Nice To Haves

5 years' management experience highly preferred.
Certified Risk Adjustment Coder Certification is preferred.

Responsibilities

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.