This position is responsible for creating plans and managing activities in support of governmental products where risk adjustment methodologies apply. Directs the daily activities of direct reports supporting risk adjustment programs and activities. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement. Implements strategic and tactical improvements to the risk adjustment program and processes. Contributes to the establishment of strategic direction on the risk adjustment program. Manage information that will ensure accurate revenue projections.
- Contribute to the department’s strategic planning efforts by identifying both strategic and tactical opportunities for improvement and recommending solutions.
- Provide day-to-day managerial oversight for staff responsible for risk adjustment programs and activities. Ensure continuous improvement of processes and delivery of results within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimizes the use of resources in assigned area using proven resource management techniques.
- Assess the impact of potential or actual regulatory changes impacting the assigned area. Ensure ongoing compliance in all activities within the assigned area.
- Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Work closely with management from other areas to ensure that appropriate processes are in place to increase data accuracy.
- Accountable to deliver on initiatives requiring cross-functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners.
- Identify risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties and work with management to mitigate this risk.
- Participate in the identification, evaluation, and management of risk adjustment-related vendors, with an annual vendor spend that is over $35M that generates revenue in excess of $100M. Assist with the preparation of RFPs, evaluation of responses, selection of vendors, and execution of pilot programs or proof-of-concept efforts.
- Oversee the creation of presentations, reports, and documentation; collaborate and negotiate with departments who are stakeholders in or dependencies of the risk adjustment processes.
- Partner with PMO, stakeholders, IT, and others to deliver and maintain the infrastructure needed to support the risk adjustment processes, as well as analytics for both Stars and revenue management.
- Other duties as assigned or requested.
- Bachelor’s degree in business or health administration, statistics, finance, information technology, or related field
- 3-5 years’ experience in a health insurance field
- 3-5 years’ experience mentoring others
- Prior management experience
- Extensive knowledge of health insurance and/or provider operations
- 2 years’ experience in developing strategic and tactical solutions to diverse and complex business problems
- 2 years’ experience in developing, communicating, and presenting concepts to varying audiences
- 3 years’ experience using project management techniques
- The ability to manage multiple projects and successfully manage projects with internal areas and external clients is required.
- Strong oral, written, presentation, and negotiation skills as well as analytical and conceptual skills are required.
- The ability to comfortably and professionally interact with all levels of management and varied skillsets.
- Knowledge of query tools and financial analysis tools is preferred.
- Experience managing a diverse professional staff is also required.
- Must be able to take charge of and be accountable for management of staff working on multiple projects to ensure corporate deadlines and objectives are met. Ability to motivate high performance, multi-disciplinary teams. Demonstrated abilities in relationship management
- Respond to feedback and champion process improvement initiatives within assigned area
- Strong leadership, coaching, mentoring abilities that will develop/maintain a high-performing team
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