Director, Risk Adjustment

Director, Risk Adjustment

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources. HCP's vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP's mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team? Position Summary: The HealthCare Partners Director, Risk Adjustment is responsible for ensuring that risk scores for HCP government sponsored members are appropriate for the acuity of the members. Risk adjustment can be performed using provider education, prospective or retrospective methods. The Director is responsible for the oversight of the technical and operational aspects of all of these programs. The Director will establish, monitor, and/or maintain the processes, IT systems and services that collect and process the data from claims, encounters, electronic medical records, medical record coding, annual wellness/comprehensive visits with PCPs, and in-home assessments. In addition, the Director must oversee the mission-critical function of building and monitoring audit functions. The Director will need to collaborate with the existing compliance teams, whose soundness will significantly mitigate compliance and financial risk to the HCP organization.

Essential Position Functions/Responsibilities:

• Responsible for the execution and oversight of the Risk Adjustment Program while, providing leadership and participation in risk meetings as an active member of the team, to discuss policy, strategy, implementation, administration, goals, progress, and improvement of the risk program.
• Promotes risk programs to meet all regulatory requirements.
• Work collaboratively with plans to ensure all risk adjustment data submission process are ensuring revenue integrity.
• Manages staff in the Value Based Performance division, which includes, but is not limited to, the coding team.
• Sets goals and plans of Risk Adjustment program (In conjunction with SVP, Quality and Clinical Revenue Integrity).
• Creates planning timelines and resource requirements; works with staff and Analytics to determine dollars at risk.
• Oversight of day-to-day coding team tasks to ensure that accurate and complete coding is performed by all HCP partners and vendors.
• Collaborates with finance on prospective and retrospective review programs.
• Partners with compliance and finance to ensure compliance with CMS rules and regulations in order to prepare for RADV audits.
• Creates long-term plan to use technology and other resources to provide more and better information to network providers.
• Actively participates with Network to give training and feedback on risk adjustment.
• Facilitates the development of tracking and monitoring mechanisms for all projects.
• Serves as SME in meetings.
• Escalates gaps in projects to SVP of Quality and Clinical Revenue Integrity, and other senior management when identified.
• Responsible to comply with State Medicaid and CMS regulations with respect to Risk Adjustment rules.
• Manages vendor contracts and looks for effective ways to reduce use of vendors and build internal knowledge/use internal resources.
• Contributes to risk adjustment functions related to Concurrent Review, Care Management, Quality Improvement, Government Contracts, Compliance, and Provider Engagement as outlined by the HCP Senior Leadership and dictated by health plan needs.
• Assists with continuous Quality Improvement activities.
• Contributes to the achievement of HCP goals and objectives by performing other duties as assigned.

Qualification Requirements: Skills, Knowledge, Abilities

• Strong analytics and/or finance background preferred.
• Background in supporting risk adjustment activities and clinical informatics in provider or health plan environment.
• Proficiency with all other risk adjustment methodologies.
• Knowledge of coding, HCCs, risk adjustments concepts, medical record review project management, encounter data management, compliance audit concepts.
• Knowledge of change management.
• Knowledge of Lean, 6 Sigma, and 5S technologies.
• Knowledge of regulations related to data submission for Medicare Advantage, MMP, and Marketplace risk adjustment.
• Knowledge of 837I (5010) formats and file protocols.
• Strong problem-solving ability and a customer-centric focus.
• Highly organized with a strong attention to detail.
• Strong communication and documentation skills.
• Fluency in Microsoft applications including Excel and Access.
• Ability to learn SQL coding as needed.

Training/Education:

• Bachelor's degree in healthcare related, engineering, business, economics, statistics, or mathematics, preferred or equivalent working experience required.
• CPC or CRC Certification in good standing.

Experience:

• 5-7 years' experience in Risk Adjustment
• 3+ years' experience as a manager or people leader
• Prior experience with risk adjustment projects
• Prior experience with interpreting CMS Advanced and Final notices

Base Compensation; $160,000-$190,000 annually Equal Employment Opportunity Statement: HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Job Disclaimer: The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.