Program Manager-Risk Adjustment

Blue Cross of Idaho•Meridian, ID

1d•Hybrid

About The Position

This job requires an experienced detail-oriented and highly analytical person to lead, manage and oversee risk adjustment programs and effectively understand and implement vendor programs and ensure contract SLAs and deliverables are met. This position has preference to be based in a hybrid work location (onsite and WFH), with a potential opportunity for fully remote work within a mutually acceptable location.

Requirements

5 years’ Medical Coding, Program Management, or Health Industry experience
Bachelor’s Degree or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)

Nice To Haves

Certified Professional Coder Certification (CPC)
Clinical Research Coordinator (CRC)
Local presence in Idaho
Experience in healthcare industry
Business Continuity Certification Preferred (CBCP, MBCP, BCCE, etc.)

Responsibilities

Monitor and analyze program performance metrics and identify trends to enhance overall accuracy of risk programs. Including report creation and monitoring of KPIs.
Stay current with industry and governmental regulations, guidance and best practices related to risk adjustment, healthcare compliance and coding accuracy.
Develop training materials and educational programs to enhance the understating of risk adjustment practices among internal and external stakeholders including but not limited to brokers, members, Care Managers, Customer Service, executive leaderships, Compliance, Legal, and other internal departments.
Create and revise policies, procedures, and protocols relevant to program activities.
Identifies opportunities to reduce risk in audits and other government reviews of risk adjustment programs and practices.
Work closely with Legal and Compliance on wording used in risk adjustment communication.
Identifies issues determined to impact risk adjustment and works with the affected teams and vendor partners to resolve them in a manner that complies with internal and external governing rules and regulations.
Supports audits to ensure complete and accurate coding and reporting of documented member chronic health conditions.
Participate in the development and implementation of innovative solutions to optimize risk adjustment processes.
Serve as a risk adjustment coding subject matter expert.
Keep thorough documentation of processes and steps taken for audit purposes. This includes, but not limited to program implementation guides.
Present at risk adjustment related conferences, seminars, meetings, and other speaking engagements.
Collaborate with cross-functional teams, including, Provider Engagement, Risk Adjustment Coders, Data Analysts, vendors, Quality/HEDIS, Healthcare Operations, Compliance, Legal, Marketing, Corporate Communications, IT and Procurement to streamline processes, ensure compliant timely execution and to support data integrity.
Perform other duties and responsibilities as assigned.