Manager, Risk Adjustment - Health Plan

Sanford Health•Marshfield, WI

About The Position

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. The Manager, Risk Adjustment is responsible for managing and overseeing the end-to-end execution of the Risk Adjustment Program, including strategy and operations for all health plan government programs (ACA and Medicare Advantage). The Manager of Risk Adjustment will have oversight of end-to-end risk adjustment operations, programs, strategy, and data integrity; risk adjustment vendor selection, implementation, and quality oversight; retrospective and prospective program design, implementation, and oversight; design and oversight of Hierarchical Condition Category (HCC)/clinical documentation operations, quality oversight, education, and analytics. The Manager will work across multiple operation teams to develop or improve systems, processes and tools that will help with the identification of diseases, assessment of the diseases and care gaps with proper documentation to ensure accurate submission of information to payer entities. The Manager must also be adept with developing tactics to meet program goals and metrics. Additionally, may be responsible for: financial management, forecasting, and integration across the managed care enterprise; comprehensive program integration to align with corporate initiatives to drive quality improvement and medical trend management; comprehensive provider education and engagement strategies; Risk Adjustment Data Validation (RADV) and overpayment recovery mitigation and preparedness strategies; and federal and regulatory policies and procedures related to risk adjustment. Will have oversight of complex analysis, assessment, and implementation of comprehensive risk adjustment programs for financial reporting and projections; general risk adjustment program audit, design and implementation; and policy and regulatory compliance. Accountable for the design, launch, manage, and oversee risk adjustment operations with recommended opportunities for improvement within the following categories for risk adjustment: optimizing revenue strategies, maximizing analytics, reducing audit and financial risk, closing data gaps, responding to regulatory changes, and driving performance outcomes.

Requirements

Bachelor’s degree required in Business, Healthcare, Information Systems, or any other applicable field of study.
3 years’ experience in the risk adjustment and Medicare managed care environment, including technical requirements as well as challenges health plan and provider clients may have in meeting reporting requirements.