Resp & Qualifications

PURPOSE: 

The Risk Adjustment Business Operations Director oversees the outcomes and business operations of risk adjustment for Medicare Advantage, Medicaid, ACA/BHP markets. The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key functions, overseeing enterprise risk adjustment performance while identifying areas of improvements and implementing in year programs. In addition, the Director evaluates, modifies, maintains & executes the provider facing Risk Adjustment/Risk Adjustment Data Validation (RADV) programs & actions across all the assigned populations and products. This role collaborates and partners with Risk Adjustment Operations Team and enterprise stakeholders across to manage performance and programs to improve accuracy.

ESSENTIAL FUNCTIONS:

• Define and establish standards and frameworks for in year Risk Adjustments related to KPIs, OKRs, ROI, action plans, progress and risks. Establish programs for key data elements to meet industry standards and assess risks adjustments across all relevant risk domains. Develop and manage tracking tools, dashboards, and metrics for monitoring the progress of the Risk Adjustment Program across all lines of business. Drives member and provider interventions closely to ensure comprehensive quality of care that includes preventive medicine screenings and the ongoing assessment and evaluation of chronic conditions.  Support the development and delivery of enterprise and market wide training and awareness materials that educate associates and leadership on best practices, pervasive operational risk adjustment issues, risk adjustment tools and processes, and lessons learned. 
• Oversee the enterprise risk adjustment process, including impact analysis and actions related to risk adjustment-related regulatory changes. Drive to implement appropriate changes necessary across CareFirst teams and processes to impact business outcomes through development of action plans. Collaborate across the eco-system such as CMS, State, District & BCBSA to drive necessary regulatory improvements. Ensure that risk adjustment activities and decisions are aligned with strategic goals and objectives, and are executed in consideration of the impact on the organizations goals.
• Establish standards for in year programs and provide advisory support in the completion of Risk Adjustment processes, as well as govern, support, and mentor associates within the prospective & retrospective strategies to ensure accurate and complete RADV mitigation, encounter & ACA EDGE submissions. Develop and implement action plans related to accurate and complete prospective, retrospective, and regulatory data submissions affecting assigned products and plans, including detailed work plans, issue logs, and progress reports at the Plan, Provider, LOB, member level. Serve as an SME to guide CareFirsts VPs of Enterprise Quality, Stars & Risk Adjustment & Network along with Actuarial and P/L owners for each line of business, regulatory filings, and financial performance planning & reporting.
• Forge and maintain strategic partnerships across the enterprise to identify risks, improve control effectiveness, and drive cross-functional process improvements that support organizational objectives. Lead, mentor, and develop teams, vendors, and project resources by establishing performance expectations, monitoring goals and milestones, implementing corrective actions as needed, and ensuring alignment with Risk Adjustment strategy, business goals, and organizational priorities

SUPERVISORY RESPONSIBILITY:
This position manages people - 1-5 5-10

QUALIFICATIONS:

Education Level: Bachelor's Degree in Health Care Administration, Public & Population Health, Finance, Business Analytics, or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience:

• 8 years of progressive responsibility in healthcare. 
• 3 years specifically in risk adjustment environment, within healthcare insurance within Government Programs (MA & Medicaid) & ACA.

Preferred Qualifications:

• Masters in Business Administration, Masters in Health Administration or Masters in Public or Population health or a related field.
• Extensive experience leading Risk programs for Medicaid, Medicare Advantage, and ACA/BHP populations, including RADV, encounter data, and ACA EDGE submissions.
• Deep knowledge of CMS regulations, HCC coding methodologies, risk adjustment operations, provider engagement strategies, and healthcare regulatory requirements.
• Proven ability to drive enterprise-wide performance improvement through analytics, KPI/OKR development, program governance, regulatory compliance, and cross-functional stakeholder collaboration.
• Demonstrated success leading high-performing teams and strategic initiatives while partnering with executive leadership, actuarial, quality, network, finance, and operational departments to achieve organizational and financial objectives.

Knowledge, Skills and Abilities (KSAs)

• Knowledge and experience across all regulatory guidelines on Risk Adjustment.
• Experience successfully planning and leading presentations to physicians, internal stakeholders, and C-suite with a focus on coding data and analytics. 
• Experienced with effective physician/provider collaborative training to support workflow adjustments to improve clinical coding quality. 
• Successful completion of a Coding Certificate program from an accredited organization (i.e., CPC, CRC, CPMA from AAPC, or CCS, CCS-P from AHIMA. 
• Strong leadership skills, Risk Adjustment financial acumen, vendor oversight skills & an experience in payer, provider & industry collaboration. 
• Ability to work in a fast-paced environment and drive consistent actions across a matrixed environment.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  
  
  

Salary Range: $140,640 - $261,063

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