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Capital Blue Cross · 6 hours ago

Director Risk Adjustment Program

Harrisburg, PA

Full-time

Onsite

Mid, Senior Level

7+ years exp

Capital Blue Cross is seeking a Director for their Risk Adjustment Program to oversee Medicare and ACA strategies and operations. This role involves ensuring regulatory compliance, managing risk adjustment processes, and leading a team to improve quality of care and reimbursement outcomes.

ConsultingHealth CareHealth InsuranceProfessional Services

Responsibilities

Actively monitor performance, productivity, and staff development activities

Lead and oversight Risk Adjustment functional areas driving optimal outcomes: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Programs

Guide and oversees the creation, implementation, and monitoring process of the Risk Adjustment Program strategy, objectives, tactics, and initiatives to drive a year over year quality of care improvements, appropriate reimbursement, and compliance with CMS mandates, regulations, and audits

Lead oversight of Risk Adjustment vendors. Lead in the identification, evaluation, and management of risk adjustment vendors. RFPs readiness, potential vendors evaluation, selection, project implementation, etc. Support Vendor Alliance negotiations activities. Support the execution of MSAs, BAAs, contracts, and SOWs with clear compliance and service level agreements

Acts as subject matter expert, maintain up-to date knowledge and interpret applicable federal and state regulations, CMS guidelines and requirements, and Medicare and ACA models transferring knowledge to leadership and cross-functional teams, etc. Implement a governance structure that provides significant oversight and audit readiness. Build statistically sound strategies to evaluate, monitor compliance, and educate senior management of any potential risk and implement appropriate remediation activities. Collaborate with the Government Program Compliance Officer to develop, execute and continually refine a quality assurance program to monitor, audit and improve the CBC Risk Adjustment Program. Develop and implement remediation strategies as needed with individual providers, provider groups, internal teams, etc

Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies. Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals

Ensure the coordination of processes, protocols and data flow between risk adjustment and cross-functional teams like care management, HEDIS, etc. resulting in appropriate follow of care and quality of care improvement’s activities

Lead the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability

Lead, develop, and mentor the Risk Adjustment team

Other duties as assigned or requested

Qualification

Risk Adjustment Program ManagementCMS HCC CodingFinancial AnalysisMedicareACA RegulationsMicrosoft Office ProficiencyProject Management ToolsAnalytical ThinkingLeadership ExperienceInterpersonal SkillsTeam Collaboration

Required

7 years experience working with Medicare Advantage Plans experience

5 years experience overseeing and leading Risk Adjustment Program

3 years experience building and leading efficient operations and successful teams

Bachelor's degree in business administration, Health Management/Administration, Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics, Public Health or Health-related Sciences; or additional 4 years of relevant experience in lieu of degree

Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand

Proven success on building and maintaining positive relationships

Exemplary of a highly collaborative team approach

Ability to influence and persuade people to collaborate and execute toward a common goal

Successful record of managing people and multiple projects with excellent results, meeting desired outcomes and goals

Eager to work with sense of urgency aligned with priorities, overcome obstacles, if needed seek for support early driving the best results to positive impact the Company and team goals

Ability to think analytically to resolve issues; solution-focused mindset; creative, innovative, and compliance thinker

Proven leadership experience in an agile and dynamic work environment

Able to connect and influence direct reports and/or team members across the organization driving collaboration /teamwork

Ability to prioritized tasks and shift readily between 'big picture' and small-but-critical details

Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions

Advance proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Project Management tools, Teams/WebEx/ZOOM

Mastery of CMS HCC Risk Adjustment coding and data validation requirements

Strategic mindset, action and results oriented keeping the department/units moving forward by making good and timely decisions meeting goals and objectives

Advance understanding of the Medicare and ACA Risk Adjustment models and regulations/enforcements

Strong financial acumen by using financial analysis to develop, evaluate, and/or act on strategic opportunities