Sr. Director, Risk Adjustment Modeling Analytics & Submission

Horizon Healthcare Services•Hopewell, NJ

About The Position

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. This position will lead the data, analytics and modeling work for the Enterprise Risk Adjustment department responsible for overall strategy and implementation of data, reporting, and model development including actuarial work product like forecasts, valuation, and pricing models and the design and oversight of Horizon’s risk adjustment data and encounter submission platforms. The position will interface with key finance and business leaders on risk adjustment data, analytics, and submissions providing strategic direction, oversight, and updates to critical risk adjustment data processes. This role is accountable for the end to end data solutions for risk adjustment from data ingestion, data management, model development, reporting, analysis, and submission of data to vendors, internal teams, and government agencies. This role will design and oversee the build of innovative predictive models related to risk adjustment and the financial performance of risk adjusted lines of business. This role reports to the Vice President of Medical Economics and Risk Adjustment and will need to operate in that capacity at times representing the department and broader Health and Network Services divisions in meetings with internal and external partners contributing to long-term planning, strategy development. This position will develop and govern a joint IT and risk adjustment data strategy including internal and external data plus tools and techniques, establishing long-term functional needs for the Health and Network Services division and crafting a roadmap to achieve those goals. This position will be accountable for reviewing actuarial work product, presenting to the Department of Banking and Insurance, and signing actuarial filings related to forecast, valuation, pricing, and actuarial opinions related to risk adjustment, reinsurance, and other work product related to operating in risk adjustment markets. This position will be lead cross-divisional workgroups to collaborate on product, network, and service operations design in order to optimize and align the enterprise across risk adjustment programs specific to each impacted line of business. This position will evaluate the markets we operate in, establish goals based on data and evidence, and drive initiatives across enterprise teams in order to accelerate adoption. This position will be expected to develop and manage the overall analytics strategy for the Risk Adjustment and Medical Economics teams developing resource plans, tool, technique, and skill roadmaps, providing assessment, mentoring, and training of analytics managers and staff when and if necessary to achieve the department’s analytics needs. This position will oversee the implementation and operation of risk adjustment data and submission platforms providing oversight, guidance, and monitoring functions for the enterprise. This role will interface with state and federal counterparts advocating for Horizon and its members, troubleshooting risk adjustment and submission processes, and facilitating state, federal, and Horizon initiatives and priorities. This is a senior level position that receives minimal guidance and requires a self-motivated individual with strong leadership, strategy, and communication skills.

Requirements

Requires a bachelor’s degree from an accredited college or university in mathematics, statistics, actuarial science, or related field.
Requires a Fellow of the Society of Actuaries credential and extensive knowledge of actuarial practices for the healthcare and managed care industry including reserving, forecasting, rate development, underwriting principles, and alternative financial arrangements.
Minimum of ten (10) years’ working experience in healthcare, health insurance, or other insurance field with hands on experience with pricing, analytics, and modeling for ACA, MA, and Medicaid lines of business.
At least seven (7) years’ supervisory experience of data scientists and actuaries required.
Requires extensive experience with clinical and claims data.
Hands on experience with analytical work to support business decisions is a must.
Requires extensive knowledge of spreadsheet software packages such as MS Excel and statistical programming software such as SAS and R, structured query language (SQL), and statistical modeling or other advanced analytics techniques.
Requires strong working knowledge of analytical techniques and actuarial practices, extensive problem solving ability, strategy development, and excellent leadership skills.
Requires demonstrated experience in managing and mentoring data teams.
Ability to set and communicate guiding goals, measure accomplishment, hold people accountable, and give useful feedback.
Requires experience developing, reviewing, and negotiating vendor services agreements.

Nice To Haves

Experience with Python or other scripting languages is a plus.

Responsibilities

Design, implement, and manage a market leading risk adjustment data and analytics strategy for Commercial, Medicare, and Medicaid risk adjustment programs identifying, valuing, and optimizing outreach to close risk and clinical gaps with an emphasis on quality of care and revenue optimization and submitting error free on time encounter data submissions to state and federal agencies.
Develop analytic and predictive models identifying patterns and trend in risk, network performance, coding accuracy, and clinical data to measure and improve risk adjustment outcomes and optimize risk scores, develop intervention strategies for improvement, and collaborate across divisions to achieve positive change.
Analyze enrollment, claims, and clinical data to influence perspective on risk and identify opportunities to capture risk and optimize coding and improve the accuracy and completeness of encounter submissions.
Provide regular reporting of model and submission results to assist risk adjustment operations, provider education efforts, and business unit, network, and product teams to manage their operations.
Generate useful datasets for consumption by business units and other data teams for the purposes of analyzing risk and risk adjustment data through time and across lines of business.
Advise the Chief Actuary and Chief Financial Officer on the activities related to pricing and managing enterprise performance with regard to risk adjusted providing data driven, actionable insights.
Advise leadership on the development of goals, long-term risk adjusted strategy, and risk-based performance measures.
Collaborate with the EVPs of commercial and government programs to establish annual goals for risk adjustment performance.
Develop, measure, and improve on goals related to risk adjustment for the enterprise.
Responsible for the growth, development, and management of staff.
Develop data and reporting to proactively identify problems or opportunities related to product development, network design, healthcare management programs, and pricing practices and direct cross-divisional work groups with commercial, government programs, and healthcare management teams to drive productive change.
Oversee actuarial staff in application of mathematics, probability, statistics, finance, and actuarial principles to manage risk, reinsurance and risk adjustment forecasts overseeing the development of accurate inputs to the enterprise forecast process.
Oversee the production of high quality actuarial work product and sign actuarial opinions and filings to the state and federal government.
Maintain and improve levels of analytical and modeling knowledge for the team.
Contribute to the general analytical knowledge of the enterprise through participation in the management of the enterprise analytics strategy and proactively recommend and assist in implementation of improvements.
Present various risk adjustment materials or status to Horizon leadership.
Escalate issues or other departmental problems and track them to resolution.
Manage the department and vendor budgets for risk adjustment.
Support management through ad hoc reporting and special projects.
Oversee the ongoing operation of enterprise risk adjustment data submission platforms.
Ensure on-time, accurate, error-free, and complete data submissions in the long-term by anticipating market changes and responding to regulator changes to ensure continuity of the process by staying current on emerging trends.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.