Director, Risk Operations

Your Future is our Future

At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.

Position:
Director, Risk Operations

Position Summary:
Provides strategic direction and is accountable for developing and ensuring the successful execution of Risk Adjustment solutions for all clients. Develops processes and directs execution that remain abreast to best practices to support an effective and sustainable Risk strategy. Responsible for program maintenance, compliance with standards, and reporting and monitoring for key performance measurement. Directs and facilitates implementation of new and existing healthcare Risk Adjustment initiatives. Accountable for utilizing analytics coupled with clinical technology to maximize growth and impact continuous improvement in appropriate documentation and coding solutions.

Job Description:

Primary Responsibilities

• Provides strategic direction and oversees, coaches, mentors, motivates, supports, and develops a large cross-functional team of advanced individual contributors and/or people leaders. Oversees and supports goal setting/review, regular guidance and 1-1 check ins, career development/planning, upskilling, resource allocation, staffing, budget management, DE&I initiatives, and other People & Culture programs/activities as needed. Fosters accountability and collaboration to ensure team member and overall team success.
• Directs the strategy and execution of Risk Adjustment engagements taking ownership of engagement deliverables, resources, and outcomes.
• Guides and oversees Risk Adjustment team members to execution.
• Delivers recurrent status reports and updates to internal and external partners.
• Identifies and raises potential and realized escalations with potential solutions providing root-cause analysis.
• Collaborates with internal and external partners to ensure ongoing alignment with long-term and short-term Risk Adjustment solution goals, activities, and intended outcomes.
• Advises development and implementation of Risk Adjustment solutions by addressing issues identified by the business units, including project plans and progress reports.
• Oversees and ensures successful completion of internal and external Risk Adjustment Data Validation (RADV) Audits; develops and oversees processes pertaining to RADV, submission, and reconciliation to ensure full compliance with all applicable laws, guidance, and regulations. Provides detailed reporting and oversight for data submission activities, minimizing variance between data sets.
• Grows professional, regulatory, and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
• Oversees physician education and engagement strategy and execution for risk adjustment, as well as national/market-based coding and related vendor relationships.
• Guides technological advancement. Oversees the development and execution of risk adjustment solutions and tools that ensure timely and accurate assessment of chronic conditions.

Qualifications

• Bachelor's Degree in Health Administration, Business Administration, or equivalent
• 12+ years of experience or the knowledge, skills, and abilities to succeed in the role
• Significant Healthcare experience including payer, hospital, Medicaid/Medicare, provider environment or managed care
• 5+ years of leadership experience within Healthcare industry or the knowledge, skills, and abilities to succeed in the role
• Proven ability to influence cross-functional teams in a heavily matrixed environment
• Excellent knowledge of Risk Adjustment Payment methodologies
• Comprehensive understanding of the CMS HCC Model and tactics that impacts results/accuracy
• Outstanding organizational and written communication skills
• Topnotch leadership skills and ability to collaborate at all levels, internally and externally
• Demonstrated commitment to best practices, continuous process improvement, and effective change management
• Exceptional analytical and quantitative problem-solving skills
• Ability to travel up to 50%

Preferred:

• Commercial Risk Adjustment experience
• Master's Degree

Working Conditions

• While performing the duties of this job, the employee works in normal office working conditions.

#LI-Remote

Pay Transparency:

Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.

The hiring range for this position is:
$153,800.00-$210,650.00

Benefits of working at Lumeris

• Medical, Vision and Dental Plans
• Tax-Advantage Savings Accounts (FSA & HSA)
• Life Insurance and Disability Insurance
• Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
• Employee Assistance Program
• 401k with company match
• Employee Resource Groups
• Employee Discount Program
• Learning and Development Opportunities
• And much more...

Be part of a team that is changing healthcare!

Member Facing Position:
No- Not Member or Patient Facing Position

Location:
United States

Time Type:
Full time

Lumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.

Disclaimer:

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential job duties and responsibilities.

Lumeris is an EEO/AA employer M/F/V/D.