POSITION SUMMARY The Manager of Risk Adjustment is responsible for managing a team of professionals to meet the needs of the Medicare and Marketplace lines of business as it relates to risk adjustment.
The Manager will work in collaboration with other business leaders, and clinical leadership to develop and implement comprehensive strategies to manage and drive improvement in end-to-end clinical documentation process, from on-boarding to claims submission and reporting.
ESSENTIAL DUTIES AND RESPONSIBILITIES Manage all risk adjustment activities, including developing process flows, establishing, tracking, and meeting deadlines, managing vendor execution within contract requirements, coordinating all submission and reconciliation with internal and external stakeholders Lead Risk Adjustment Work Groups and deliverables in collaboration with Medical Director Create work plans and timelines for projects and supervise and manage the day-to-day responsibilities of the Risk Adjustment Coordinators, providing relevant training and delegation of new projects as needed to achieve team goals Guide process improvement efforts around coding, claims process and overall revenue cycle management.
Track overall portfolio of projects/initiatives and integration with other key functional teams’ work plans.
Evaluate the risk adjustment strategy and submission processes of clients to identify improvement opportunities Provide support and guidance on risk adjustment and clinical quality operations, accreditation, quality improvement initiatives Support root cause analysis and develop targeted interventions designed to improve clinical quality and risk adjustment outcomes Work with Financial Planning and Analysis to track and evaluate the impact of initiatives and programs.
Manage vendor relationships to support coding, claims processing, billing and collections efforts.
Leads audit strategies of delegated parties and in plan’s regulatory risk adjustment data validation audits.
Model and trend RAF and risk adjusted revenue and utilization costs by PMPM by plan and line of business to determine and make recommendations on overall revenue cycle impacts on an at least quarterly basis Calculate ROI on all vendor programs and make recommendations on contract continuation and negotiation Accepts and performs other duties as assigned.
QUALIFICATIONS Bachelor’s degree in business, health administration, health policy, finance or a related field is required.
Master’s degree preferred 3-5 years of experience in Medicare and Commercial Risk Adjustment 2 years of people management experience required Experience working multiple concurrent projects Demonstrates strong analytical and decision-making skills Demonstrated success in independently planning and managing multiple projects and reevaluating priorities in a self-directed manner and meeting challenging deadlines, and be willing to work long and flexible hours during peak project times to get the job done Preferred Qualifications: Undergraduate degree; Master’s degree a plus Certified Risk Adjustment Coder (CRC) Risk adjustment experience across multiple product lines (i.e., Medicare, Medicaid, ACA) Quality expertise (HEDIS, NCQA Accreditation, Star Ratings)