Manager, Risk Adjustment Operations and Provider Consulting

Point32Health, Inc • Canton, MA

62d • $109,060 - $163,590

About The Position

This position will lead the Risk Adjustment Operations & Provider Consulting team responsible for the department's program management, provider engagement and consultation activities supporting the complete and accurate capture of risk adjustment data. To be successful, the Manager will need to rely on strong analytic, consultative and communication skills to develop and execute strategies related projects and programs (internal and vendor-driven) that optimize performance across our provider networks serving Point32Health's Medicare, Medicaid, Duals and Commercial small and individual group markets. This position will leverage qualitative and quantitative information to develop and refine provider specific engagement plans that align with our corporate and business division goals. This position will report to the Director of Risk Adjustment Strategy, Operations and Quality Assurance.

Requirements

• Minimum six years in a progressively responsible role with leadership experience in a complex operational setting or consulting role.
• Previous experience working in strategy development and implementation, analytical and process improvement in the health care / health plan sector or management consultancy.
• Highly organized, self-motivated, detail-oriented, and energetic team player who can also work independently.
• Analytical thinker with strong consultative skills.
• Working knowledge of both the medical and business side of health plan and provider operations.
• Ability to understand and navigate complexity and regulation.
• Strong leadership skills with proven ability to lead change to accommodate evolving organizational and regulatory processes.
• Strong communication, influencing and partnering skills at all organizational levels across internal functions and with business and medical leadership at physician organizations.
• Strong one on one, small group and large group communication skills.
• Excellent judgment, critical thinking, and decision-making abilities.
• Strong process management and project management skills.
• Ability to work with data (including financial data) to identify trends and identify process improvements.
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Bachelor's degree required.

Nice To Haves

• Experience working with CMS, state agencies, health insurers, medical provider systems and/or risk adjustment desired.
• Graduate degree preferred.

Responsibilities

• Provider Consulting, Risk Score Reporting and Collaboration: The Manager will oversee all provider engagement and reporting activities for risk adjustment programs and initiatives that impact Medicare, Medicaid, and Duals product members. This individual will lead the development and implementation of provider-specific analyses and engagement plans, and design effective risk adjustment optimization strategies for the markets we serve. This individual will oversee the analysis, interpretation and synthesis of medical group specific results and risk score trend information; develop dashboard reporting and a regular schedule for delivering the results of standard (and ad hoc) analyses to improve awareness and understanding of risk adjustment results and the quality, accuracy and identification of member health conditions. The Manager will build relationships and drive risk adjustment engagement with senior leaders at contracted provider organizations.
• Risk Adjustment Program Management and Vendor Evaluation: The Manager will be responsible for risk adjustment program management and key supporting functions including the development, implementation and ongoing management of contracts that require the highest levels of service delivery from external vendors. This individual will regularly review the effectiveness of programs, processes, infrastructure and reporting to identify improvement opportunities and recommend changes to improve program results and effectiveness. The Manager will collaborate with key internal stakeholders (Clinical, Contracting, Provider Partnerships, Actuarial, Procurement and Compliance) to refine prospective and retrospective diagnosis coding programs. This individual will oversee team efforts to assess additional program opportunities that can be procured or potentially developed internally; and take a leadership role in collaboration with Procurement during contract negotiations. The Manager will frequently present upon the effectiveness of risk adjustment initiatives and programs to both internal senior leaders and external stakeholders.
• Strategy Development and Project Management: The Manager will support department leadership in strategic planning efforts and annual risk adjustment business plan development. They will drive execution against that business plan while optimizing collaboration between Risk Adjustment and other departments or areas that are external facing such as Contracting, Actuarial, Procurement, Provider Partnerships and Care Management / Clinical Affairs. The Manager will oversee the team's project management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. This individual will utilize performance analysis methods to identify and recommend opportunities for process improvement across the department. The Manager will also help lead the current-state assessments of provider organizations' risk adjustment capabilities in new markets or regions.
• Revenue Tracking and Financial Reporting: The Manager will support department leadership by collaborating across business divisions and functions to coordinate the development and refinement of financial dashboards and reporting that identify and track revenue trends and program results for Medicare, Medicaid, Duals and or Commercial small and individual group market membership. The Manager will collaborate with Actuarial and analytical teams within the department to understand and monitor the financial impact of risk adjustment programs.
• General Management: The Manager will lead a team of six peoples (three risk adjustment consultants and three program management professionals).
• Other duties and projects as assigned.

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Number of Employees: 1,001-5,000 employees