The Director, Risk Adjustment develops and ensures effective execution of departmental strategic and operational plans in support of MPHC risk adjustment objectives. This role oversees and translates MPHC strategies into operational plans and sets the direction for the revenue accuracy and risk adjustment efforts. This Director role is a key strategic leader responsible for driving Medicare Risk Adjustment activities and achievement of related revenue targets. Primary responsibilities include leading the development, implementation, monitoring and oversight of programs, processes and operations to improve risk adjustment performance and accuracy of risk adjustment data collected and submitted to CMS. This role is also responsible for the development, analysis and reporting of key risk adjustment metrics, as well as overseeing analyses of new legislation and regulations regarding Medicare Risk Adjustment and assessing the impact of any changes in the programs.
The Director will develop effective relationships with key provider groups (bothinternal and external) and vendors to implement successfulrisk adjustment optimization efforts for Martin’s Point’s Health Planproducts. This position will also provide support for the development of new products and initiatives and must be able to influence in a matrix management environment and collaborate successfully.
- Leads the implementation of key risk adjustment optimization programs for Martin’s Point’s Health Plan products.
- Partners with Senior leadership to plan the strategic direction of Risk Adjustment initiatives to facilitate achievement of complete and accurate diagnosis capture and sustainable business performance to achieve organizational goals.
- Evaluates and oversees the development and implementation of CMSrisk adjustment program changes. Incorporates changes and requirements into strategy.
- Uses analytics to define Risk Adjustment focus and works internally with Director, Health Plan Quality to align and optimize quality and risk adjustment metrics opportunities. Leads the development of key analytics and data to support Risk Adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization.
- Educates internal and external stakeholders on changes in regulations and the critical nature of risk adjustment, and recommend areas of process improvement.
- Oversees vendor relationships with regards to chart review and in-home/mobile assessments for members
- Support targeting members for PCP visits and member outreach efforts (e.g. new member processes and annual assessment activities)
- Develops performance targets for both internal and external parties and ensures that performance targets are set and included in contracts where appropriate. Tracks progress against stated goals and drive to attainment
- Oversees an effective and optimal Risk Adjustment submission process and Quality Assurance Program
- Monitors, measures and communicate Risk Adjustment performance and submission quality relative to the program strategy
- Works to accurately assess ROI of all risk adjustment program activities
- Partners with Network Management to develop and distribute provider reporting and develop incentive programs for key provider groups as it relates to Risk Adjustment metrics and performance
- Coordinates with appropriate functional areas including Medical Management, Quality, Pharmacy, Member Services, Operations, etc. as it relates to Risk Adjustment initiatives.
- Develop and implement employee training and provider outreach programs, as needed, to improve Risk Adjustment performance.
- Work closely with the Director, Health Plan Quality to ensure delivery and integration of risk adjustment and quality programs
- Provides insight and oversight to product leadership, medical management leadership, CFO and finance team in developing forecasts and Medicare product Bids
- Assists with complex cross-functional analyses of healthcare data to identify outcomes and trends, interpret and explain results, and discover opportunities for improvement
- Supports Senior leadership in developing annual business plan, including developing annual goals and identifying appropriate initiatives to advance the performance of Martin’s Point’s Health Plans
- Develops and maintains knowledge and expertise in regional and national Medicare trends and best practices, seeking opportunities to translate those to Martin’s Point
- Bachelor’s degree in business, health administration, health policy, finance or a related field is required. Master’s degree strongly preferred.
- 7+ years Managed Care experiencerequired
- 5+ years Medicare Risk Adjustment experiencerequired
- 5+ years leadership and/or management experiencerequired
- Solid knowledge of the industry and cross–functional work experiences in the areas health insurance finance, medical economics, actuarial, underwriting, and/or risk adjustment.
- AHIMA or AAPC (CPC) coding certification Healthcare Coding Practices preferred
- Demonstrated success in improving Risk Adjustment measures.
- Demonstrated success working in a matrix environment and leading cross functional teams.
- Demonstrates an understanding of and alignment with Martin’s Point Values
- Strong analytical skills
- Strong level of understanding of actuarial and reconciliation and revenue enhancement principles
- Proven ability to make sound decisions relative to the reconciliation and revenue enhancement of Medicare Advantage products.
- Demonstrated interpersonal, communications and team building skills
- Strategic ability to see the big picture and connect dots across an organization
- Strong project managementexperience and the ability to operationalize a concept
- Proven ability to organize work, simultaneously work on many activities and projects and meet deadlines directly or through matrix management
- Demonstrated ability to develop and implement new programs or services
- Strong track record of building internal and external collaborative relationships
- Broad understanding of managed care business and financial principals such as reconciliation and revenue, medical management, physician reimbursement and risk management
- Strong oral and written communication to support executive level briefings and presentations both internal and external to Martin’s Point
- Ability to write executive reports and power point presentations, as well as the ability to present findings in internal and external settings.