Medicare Risk Adjustment Director
Responsible for the ongoing development, implementation and facilitation of the processes to assure that all pertinent clinical information impacting the risk scoring of Medicare patients is captured and transmitted to health plans. Includes participation in ongoing data mining and analysis, oversight of, development and delivery of education and identification of opportunities to improve reimbursement through proper coding and documentation. Oversees the general organization and efficient management of the Medicare Comprehensive Health Assessment Program (CHAPs) data activities in the department.
- Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
- Manages teammates working on RADV, Chart review data submission, education, analytics, and general support of corporate Medicare Risk Adjustment activities.
- Interprets, provides feedback, and acts as subject matter expert of CMS regulations and HCC reimbursement methodologies.
- Generates various analytical reports including return on investment, criteria based member selection and prioritization, and other analytical schedules related to CHAPs activities.
- Designs and manages databases related to RADV and ASM encounter data submission to support efficient and effective processes and utilizes and integrates data warehouse data as appropriate.
- Participates in quality assurance of Provider Information Portal (PiP) enhancements.
- Participates in process improvement projects related to work performed.
- Functions as primary content owner of technical and analytic tools utilized for research and analysis
- Analyzes patient and clinician data to monitor performance, validate outcomes, and identify improvement opportunities.
- Develops program strategic messaging and communication plans in partnership with Directors and others for each initiative.
- Participates in the development and creation of program training materials (e.g., job aids, presentations, etc.).
- Delivers training to various teammates and other stakeholders with fluency and credibility, facilitating a necessary understanding of key objectives.
- Assesses, responds and reacts to CMS and/or internal mandates to ensure compliance and programmatic success.
- Synthesizes complex programs and clearly communicates them to a wide range of stakeholders.
- Reviews CMS documents related to risk adjustment, synthesizes findings, and formulates recommendations.
- Uncovers insights from analyses that can be leveraged strategically, clinically or operationally.
- Attends internal team meetings and calls to ensure alignment around project objectives, deliverables, and timelines.
- Performs additional duties as assigned
- Bachelor's degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
- Master’s degree preferred.
- Experience in analytics and data analysis
- Over 5-7 years in a healthcare setting.
- Over 1-3 years management experience.
- Experience in Medicare Advantage risk adjustment programs
- Fluency in Microsoft applications.
Knowledge, Skills, and Abilities:
- Fluent in T-SQL
- Demonstrated success working in dynamic, fast-paced environment.
- Excellent analytical and problem-solving skills.
- Experience conducting root cause analysis and identifying optimum solutions.
- Ability to effectively direct preparation of various financial analysis and data mining activities.
- Excellent verbal and written communication skills.
- Ability to effectively interface with teammates, clinicians, and management.