VP Risk Adjustment Accuracy Management

GENERAL OVERVIEW:

This position is responsible for risk revenue management for all government program products (commercial ACA, Medicare, and Medicaid). Establishes the strategic direction for the Risk Revenue Management process, assessment of revenue and cost trends to achieve revenue targets and improve quality of care for our members. Drives the coordination with multiple stakeholders to implement and execute on the strategic direction and optimize our revenue management capabilities. Builds strong analytical functions to focus resources on providing optimal financial returns in a fully compliant manner. Develop a Risk Management governance strategy for the Enterprise to appropriately manage CMS audit risk.

ESSENTIAL RESPONSIBILITIES:

1. Program Development and Management:

• Provide strategic leadership and management for the Risk Adjustment Accuracy Management Department.

• Develop and oversee programs to ensure comprehensive and accurate diagnosis coding for risk adjusted government programs (Medicare Advantage, ACA business, and Medicaid). Also work with Care Management to ensure that this information is used to improve the management of a member’s care.

• Collaborate with key internal stakeholders (Clinical Services, Provider Transformation, Network Contracting, Actuarial, Finance and Compliance) to develop, implement, and continually refine prospective and retrospective diagnosis coding programs and provider support.

• Oversee execution of all coding programs and processes, both vendor supplied and internal.

• Monitor and analyze the effectiveness of 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/HHS/DPW evolves the models and guidance.

• Accountable for achieving financial targets related to risk adjustment activities and complying with all government and commercial regulations. Build financial dashboards and benchmarks for each program individually as well as all revenue programs in aggregate.

• Manage a budget of approximately $70M.

2. Quality Assurance/ Compliance

• Implement a governance structure that provides significant oversight of the governmental audit and compliance risks.

• Build statistically sound strategies to evaluate and educate senior management of the risk and rewards involved in key risk revenue strategies.

• Collaborate with the Government Program Compliance Officer to develop, execute and continually refine a quality assurance program to monitor, audit and improve the quality of provider medical record documentation, and diagnosis coding.

• Develop and enhance infrastructure and reporting to support QA programs

• Develop and implement remediation strategies as needed with individual providers, provider groups and the network as a whole

3. Analytics

• Lead a team that develops and oversees analysis of risk adjustment programs including ROI, productivity, quality, risk score/ revenue impact at the plan and provider group level.

• Lead a team that develops and supports analytics related to government quality programs such as Medicare STARS and the ACA Quality Rating System.

• Utilize analytics to identify trends and opportunities for improvement, new strategies and further program development

• Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals.

• Develop capabilities to identify both opportunities and weaknesses in the government’s actuarial risk score models to inform better business decisions

4. Operations and Data Submission

• Manage an operations team responsible for submitting accurate and comprehensive data to the government.

• Oversee both the CMS RAPS/Encounter data submissions as well as Edge Server submission for the ACA products.

• Develop, implement and oversee controls and reporting to ensure effective processes are in place throughout the organization

• Develop and oversee processes and reporting that ensure complete and timely correction and resubmission of data errors from CMS

5. Vendor Management

• Manage relationship and contracting strategy for multi-million dollar vendor contracts.

• Collaborate with Procurement to negotiate and execute vendor contracts with strong compliance and financial protections.

6. People Development

• Be a strong and effective leader focused on staff development and growth

• Communicate effectively and confidently with all levels of the organization

7. Other duties as assigned or requested.

QUALIFICATIONS:

Minimum:

• Bachelor’s degree

• Ten or more years’ work experience in health care with emphasis on analysis and process optimization

• At least five years’ direct management experience

Preferred:

• 5 or more years’ Medicare and/or Commercial risk adjustment experience

• Previous involvement with complex and unique issues and proficiency in the healthcare industry

• Credentialed Actuary (FSA/ASA) or Advanced Degree (MBA)

Language (Other than English):
None

Travel Requirement:
0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type