Roles and Responsibilities:
- Directs the strategy and execution of Risk Adjustment engagements taking ownership of engagement deliverables, resources, and outcomes. Lead and manage Risk Adjustment team members to execution.
- Provides recurrent status reports and updates to internal and external stakeholders; identifies and raises potential and realized escalations with potential solutions providing root-cause analysis.
- Partners with internal and external stakeholders to ensure ongoing alignment with Risk Adjustment solution objectives, activities, and intended outcomes, both long-term and short-term.
- Directs development and implementation of Risk Adjustment solutions; addresses issues identified by the business units, including project plans and progress reports; escalates realized and potential risks as needed.
- Provides oversight and ensures successful completion of internal and external Risk Adjustment Data Validation (RADV) Audits; Develops and oversees processes pertaining to RADV, submission, and reconciliation to ensure full compliance with all applicable laws, guidance, and regulations. Provide detailed reporting and oversight for data submission activities, minimizing variance between data sets.
- Provides leadership and direction to Risk Adjustment team; performs management responsibilities including coaching and development, performance management, and assesses competencies. Plans, organizes, and directs operations of the Risk Adjustment Department; develops and implements policies and programs as necessary.
- Stays abreast to all applicable federal and state regulations, guidance, and technical specifications; ensures activities remain within compliance.
- Serves as a subject matter expert and represents Risk Adjustment in external and internal forums.
- Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
- Other duties as assigned or requested.
Experience, Qualifications, and Education:
- Bachelor's Degree in Health Administration, Business Administration or related field required, Master's Degree preferred.
- 7 years' previous Healthcare experience including payer, hospital, Medicaid/Medicare, provider environment or managed care.
- 5 years' leadership experience within Healthcare industry required.
- Proven track record of managing people directly and influencing cross-functional teams in a heavily matrixed environment.
- 5 years' previous Healthcare experience including payer, hospital, Medicaid/Medicare, provider environment or managed care.
- Commercial Risk Adjustment experience highly preferred.
- Ability to travel up to 50%.
- Knowledge of Risk Adjustment Payment methodologies.
- Deep understanding of the CMS HCC Model, tactics that drive results/accuracy.
- Outstanding organizational and written communication skills; excellent interpersonal and oral communication skills.
- Strong leadership skills and ability to collaborate and work through all professional levels, internally and externally.
- Strong commitment to best practices, continuous process improvement and effective change leader.
- Possesses exceptional analytical and quantitative problem-solving skills.
- Results oriented with proven leadership experience in functional and matrix aligned organizations.