Director, Risk Operations

Lumeris

4d•$153,800 - $210,650•Onsite

About The Position

Provides strategic direction and is accountable for developing and ensuring the successful execution of Risk Adjustment solutions for all clients. Develops processes and directs execution that remain abreast to best practices to support an effective and sustainable Risk strategy. Responsible for program maintenance, compliance with standards, and reporting and monitoring for key performance measurement. Directs and facilitates implementation of new and existing healthcare Risk Adjustment initiatives. Accountable for utilizing analytics coupled with clinical technology to maximize growth and impact continuous improvement in appropriate documentation and coding solutions.

Requirements

Bachelor's Degree in Health Administration, Business Administration, or equivalent
12+ years of experience or the knowledge, skills, and abilities to succeed in the role
Significant Healthcare experience including payer, hospital, Medicaid/Medicare, provider environment or managed care
5+ years of leadership experience within Healthcare industry or the knowledge, skills, and abilities to succeed in the role
Proven ability to influence cross-functional teams in a heavily matrixed environment
Excellent knowledge of Risk Adjustment Payment methodologies
Comprehensive understanding of the CMS HCC Model and tactics that impacts results/accuracy
Outstanding organizational and written communication skills
Topnotch leadership skills and ability to collaborate at all levels, internally and externally
Demonstrated commitment to best practices, continuous process improvement, and effective change management
Exceptional analytical and quantitative problem-solving skills

Nice To Haves

Ability to travel up to 50%
Commercial Risk Adjustment experience
Master's Degree

Responsibilities

Provides strategic direction and oversees, coaches, mentors, motivates, supports, and develops a large cross-functional team of advanced individual contributors and/or people leaders.
Oversees and supports goal setting/review, regular guidance and 1-1 check ins, career development/planning, upskilling, resource allocation, staffing, budget management, DE&I initiatives, and other People & Culture programs/activities as needed.
Fosters accountability and collaboration to ensure team member and overall team success.
Directs the strategy and execution of Risk Adjustment engagements taking ownership of engagement deliverables, resources, and outcomes.
Guides and oversees Risk Adjustment team members to execution.
Delivers recurrent status reports and updates to internal and external partners.
Identifies and raises potential and realized escalations with potential solutions providing root-cause analysis.
Collaborates with internal and external partners to ensure ongoing alignment with long-term and short-term Risk Adjustment solution goals, activities, and intended outcomes.
Advises development and implementation of Risk Adjustment solutions by addressing issues identified by the business units, including project plans and progress reports.
Oversees and ensures successful completion of internal and external Risk Adjustment Data Validation (RADV) Audits; develops and oversees processes pertaining to RADV, submission, and reconciliation to ensure full compliance with all applicable laws, guidance, and regulations.
Provides detailed reporting and oversight for data submission activities, minimizing variance between data sets.
Grows professional, regulatory, and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
Oversees physician education and engagement strategy and execution for risk adjustment, as well as national/market-based coding and related vendor relationships.
Guides technological advancement.
Oversees the development and execution of risk adjustment solutions and tools that ensure timely and accurate assessment of chronic conditions.