Director, Risk Adjustment

UHS • Reno, NV

11d

About The Position

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience. Learn more at: https://prominence-health.com/ Job Summary: The Director, Risk Adjustment, under the supervision of the Chief Operating Officer is responsible for planning, developing, implementing, and monitoring all aspects of a robust Risk Adjustment Program across Prominence Health Plan’s (PHP) Medicare Advantage and Commercial Small Group and Exchange products. The objective of the Risk Adjustment Program is to ensure compliance with CMS coding and documentation requirements in order to optimize clinical quality and revenue opportunities for Prominence Health Plan. Key responsibilities include optimizing PHP revenue opportunities by ensuring members receive appropriate medical care that is accurately coded so that the members’ risk scores are optimized and compliant with regulatory reporting standards. The manager will have accountability for the internal ICD-9/10 process meeting CMS and DHS compliance requirements, the preparation for and management of the Risk Adjustment Data Validation (RADV) audit process and other similarly related audits, the development and implementation of the prospective diagnosis coding program, including coordinating effective provider education and training, management of the retrospective medical record review process, and vendor contract management. Must work collaboratively with other PHP departments, including Actuarial, IS, Legal, Health Services, Network Management, Quality Improvement and others to manage the risk adjustment process. Must develop or purchase tools that will result in leveraging information to manage member analytics in order to more effectively direct resources and activities to meet risk adjustment objectives. In carrying out these responsibilities, The Director works closely with external vendors and consultants, runs outsourced health risk assessment programs, develops training programs & tools to address the educational needs of providers and non-clinical staff, assists in the development of analytic and reporting tools, and assists in the development of data collection systems and workflows to fulfill CMS requirements.

Requirements

• Bachelor’s Degree in Business Administration, Finance, Health Care Administration, Management or related field required.
• Ten years of health care experience working with Medicare and/or Commercial risk adjustment programs.
• Requires working knowledge of CMS risk adjustment methodologies.
• Direct Operational knowledge of provider relations, claims and medical management is highly desired.
• Excellent computer skills. Microsoft Office.
• Personable and demonstrated ability to develop and maintain relationships at all levels.
• Strong verbal and written communication skills.
• Versatile and flexible.
• Inquisitive mind with strong analytical skills and the ability to do complex problem solving.
• Strong project management, meeting process and presentation skills.

Nice To Haves

• Post graduate degree(s) desirable.
• Direct Operational knowledge of provider relations, claims and medical management is highly desired.

Responsibilities

• planning, developing, implementing, and monitoring all aspects of a robust Risk Adjustment Program across Prominence Health Plan’s (PHP) Medicare Advantage and Commercial Small Group and Exchange products
• optimizing PHP revenue opportunities by ensuring members receive appropriate medical care that is accurately coded so that the members’ risk scores are optimized and compliant with regulatory reporting standards
• accountability for the internal ICD-9/10 process meeting CMS and DHS compliance requirements
• preparation for and management of the Risk Adjustment Data Validation (RADV) audit process and other similarly related audits
• development and implementation of the prospective diagnosis coding program, including coordinating effective provider education and training
• management of the retrospective medical record review process, and vendor contract management
• work collaboratively with other PHP departments, including Actuarial, IS, Legal, Health Services, Network Management, Quality Improvement and others to manage the risk adjustment process
• develop or purchase tools that will result in leveraging information to manage member analytics in order to more effectively direct resources and activities to meet risk adjustment objectives
• works closely with external vendors and consultants, runs outsourced health risk assessment programs, develops training programs & tools to address the educational needs of providers and non-clinical staff, assists in the development of analytic and reporting tools, and assists in the development of data collection systems and workflows to fulfill CMS requirements

Benefits

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: benefits.uhsguest.com

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 1,001-5,000 employees