Responsible for developing, implementing, maintaining, monitoring and overseeing the company's risk adjustment initiatives to include oversight of vendor activities, and the evaluation of policies and procedures used for the Risk Adjustment program to ensure compliance with all Centers for Medicare and Medicaid Services (CMS) and Rhode Island regulatory guidelines.
- Responsibilities include, but are not limited to, the following:
- Program Management:
- Collaborate with key internal stakeholders Quality Analytics , Performance Improvement, Medical Management, Provider Engagement and Contracting, Finance, and Compliance) to develop, implement and continually refine prospective and retrospective diagnosis coding programs and provider support.
- Oversee execution of all risk adjustment coding programs and processes, both vendor supplied and internal.
- Monitor and analyze the effectiveness of risk adjustment programs, processes, infrastructure, and reporting, and make changes to improve results and effectiveness.
- Identify, evaluate and implement new programs or modifications to existing coding programs and develop strategies to implement.
- Develop, oversee and adapt infrastructure (processes, systems, talent) to support an effective risk adjustment program as CMS evolves the model and guidance.
- Data Submission:
- Collaborate with Neighborhood departments and vendors to ensure timely, accurate and complete submission of risk adjustment data to CMS and ensure reconciliation of plan payments.
- Collaborate with internal departments and vendors to develop effective policies and procedures that ensure submission of risk adjustment data to CMS is timely, complete and compliant with CMS requirements.
- Develop and oversee processes and reporting that ensure complete and timely correction and resubmission of risk adjustment data errors to CMS
- Manage Risk Adjustment Accounting Requirements:
- Responsible for the development and reconciliation of Risk Adjustment revenue and expense accruals each month
- Projects estimated Medical Loss Ratio and rebate requirements
- Regulatory Oversight and Quality Assurance:
- Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
- Develop and implement strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.
- Provider Engagement, Training and Support
- In collaboration with internal departments as appropriate, develop and oversee the execution of strategies, programs and plans to engage contracted medical group physicians in proper assessment, coding and documentation of all members, complete submission of data, and engagement in company programs that support these efforts.
- Develop and implement programs for provider training and education on HCC risk adjustment, proper medical record documentation and diagnosis coding accuracy.
- Using vendor business intelligence software, develop and oversee reporting of medical group specific results to improve quality, accuracy and identification of member health conditions as relates to risk adjustment.
- Analysis and Use of Results
- Develop and oversee analysis of risk adjustment programs including ROI, productivity, quality, risk score/ revenue impact at the plan and provider group level.
- Utilize analysis to identify trends and opportunities for improvement, new strategies and further program development
- Collaborate with Medical Management leadership on the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.
- Collaborate with vendor to project and monitor the impact of coding programs on CMS revenue for budgets and plans
- Enterprise Risk Adjustment
- Coordinate and drive enterprise-wide risk adjustment initiatives.
- General Management
- Stays informed about CMS and industry trends and best practices and utilize this knowledge to refine and advance risk adjustment programs.
- Foster a comprehensive understanding of CMS guidance for risk adjustment policies and procedures within the department and with key stakeholders and providers.
- Actively participate in industry and CMS calls and initiatives related to risk adjustment.
- Management of professional level staff
- Other duties as assigned
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
- Bachelor’s degree in finance, business or health related area
- Proven leadership skills and prior supervisory experience
- Five (5)+ years’ health care or related experience
- Strong analytical / problem solving skills
- Ability to convey information / ideas clearly and effectively, both verbally and written
- 1 – 3 years’ experience managing CMS Risk Adjustment rules and regulations for Medicare Advantage and Commercial programs
- Experience with CMS Risk Adjustment processes (RAPS, EDPS, Edge Server, RADV Audit)
- Experience with vendor supported Risk Score Accuracy programs
- Understanding of medical terminology such as diagnosis codes (ICD-10), and other claims coding topics such CPT and HCPCS and related Hierarchical Condition Coding (HCC) methodologies
- Strong interpersonal skills, with the ability to interact effectively with senior management, key external partners, providers and vendors
- Advanced skills in Microsoft Office (Project, Word, Excel, PowerPoint, Outlook)
- Established negotiating skills
- CPT coding certification
- Knowledge of Medicare payment methodologies and regulations
- Knowledge of the Commercial Health Insurance market, including reimbursement methodologies, rate setting, member cost share, etc.
- SQL knowledge and ability to create queries for reconciliation
- Statistical methodologies and analysis
- Experience in Project Management
- Master’s degree
- Judgment and Decision Making
- Gets Results
- Collaboration and Teamwork
- Business Awareness
- Customer Focus
Job Specific Competencies:
- Attention to Detail
- Organizational Savvy
- Planning & Organizing
- Problem Solving & Analysis
- Strategic Thinking & Alignment