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Manages broad based risk adjustment programs for both Medicare and Medicaid to achieve program optimization Implementation of vendor risk adjustment contract execution as well as ensuring Quality assurance and compliance with federal and state requirements. Responsible for timely and accurate response to federal and state risk adjustment audits.
Manages risk adjustment programs and initiatives to help achieve the revenue appropriateness goals and objectives.
Manages contract performance and the activities of outside vendor partners across all initiatives impacting risk adjustment for Medicare and Medicaid.
Monitors the vendors' service level agreements (SLAs) and goal attainment.
Continually assesses program costs and containment.
Develops and implements Corrective Action Plans (CAPs) when necessary in order to obtain successful risk adjustment program completion and expected ROIs.
Accountable for ensuring ongoing key performance indicators measure productivity, quality, and overall impact of company's risk adjustment program. Includes reporting KPI (Key Performance Indicators) results on a monthly basis.
Manages the CAP process by providing domain expertise when responding to the Regulatory and Compliance Departments for CMS and/or other governing bodies' submission requests. Ensures representation and decision making for Compliance and/or program changes that impact our risk adjustment programs and actively participates in industry discussions.
Develops and implements Standard Operational Procedures (SOPs), work flows, and process documentation policies for risk adjustment programs.
Builds and maintains strong relationships internally, fostering support and a collaborative approach between departments with internal stakeholders. This includes, but is not limited to, collaborating with each individual market/region, working closely with the Provider Relations Network, communicating with Marcomm & Regulatory, working with Product Management, partnering with the Health Services Department, teaming up with the Business Process Improvement (BPI) Department, etc..
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A Bachelor's Degree in in a health related field and/or finance
Required or equivalent work experience Additional 2 years of work experience needed w/out Bachelors
Required 5 years of experience in managed care, Risk Adjustment, HEDIS, STARS and/or other healthcare initiatives. 3 of which in supervisory/management roles
Required 3 years of management experience
Intermediate Ability to multi-task
Advanced Demonstrated leadership skills
Intermediate Ability to work as part of a team
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Licenses and Certifications: A license in one of the following is required: