The Manager, Risk Adjustment is responsible for managing and overseeing the end-to-end execution of Risk Adjustment Programs in the local Market. You'll partner closely with provider network managers and clinical leadership in engaging the physician network to assess members for their significant and chronic diseases as well as ensuring HEDIS quality gaps data is appropriately submitted. Working across multiple operation teams you'll develop or improve systems, processes and tools to 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 Program Manager must also be adept with developing tactics to meet program goals and metrics.
How You'll Contribute:
Implements and manages the strategic plans for the risk adjustment program, including working with leadership on approaches to structure an effective risk adjustment programs in the local market.
Continually assesses the tactical processes to achieve program objectives and putting in program changes where needed
Ensures accurate and complete data capture in all programs; this includes but is not limited to: retrospective and prospective chart reviews and assessment program
Create, reviews and maintains operational workflows that are efficient and effective
Work with medical leadership to enhance electronic health record systems and tools for physician network to use
Successfully interacts with physicians and physician office staff to engage in programs developed
Oversees claims/encounter data collection, processing, submission and data reconciliation efforts with provider network and health plans ensuring that collected data is processed all the way to CMS’s RAPS system as well as EDPS system.
Develops and implements approaches to measure the effectiveness of physician specific initiatives for improving risk score accuracy.
Maintains expert knowledge of the risk adjustment process, including regulatory changes impacting the program
Ensures company approved compliance programs and P&Ps are upheld across the market
Collaborates across the company and with vendors to help ensure the integration and alignment of risk adjustment strategies ·
Leads staff assigned to risk adjustment; provides guidance and engagement of staff; and builds effective teams (both internally and with vendors) to achieve established goals and within established budgets
Demonstrates the ability to lead and influence others positively to achieve desired goals.
What You'll Do:
3 + years of experience in one or more of the following: Risk Adjustment, Quality/HEDIS, Health Care Finance, Health Care Compliance and/or General Health Plan Operations
Demonstrated experience in managing a high-volume workload and meeting tight deadlines
Ability to maintain confidential information
Experience working as part of a team to accomplish a shared objective
Working knowledge of Medicare Advantage, Part C & D laws and regulations
Familiarity with ICD-10
Microsoft Excel proficiency; Microsoft Access preferred
Bachelor’s degree (B.A.) from four-year College or university; or three years related experience and/or training; or equivalent combination of education and experience.
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