Business Analyst

Value Base Director

The value base director is responsible for leading and implementing strategies that drive value-based care initiatives. This includes overseeing projects, developing workflows, and ensuring alignment with performance-based reimbursement models to improve patient outcomes and reduce costs for the Ambulatory Division. The role also involves collaborating with various stakeholders, such as providers, care teams, finance, revenue cycle and payers, to achieve these goals. The position will support ambulatory division including Health Point in establishing Medicare Risk Adjustment, Medical Coding and Billing compliance, Healthcare auditing of documentation, revenue cycle management, risk adjustment coding for the ambulatory division. This includes all specialty and primary care. The position will function as a knowledge depository for value base revenue cycle and billing for the division. Strong relationship with the payors.

Responsibilities

Strategic Planning and Implementation-

• Developing and executing strategies for value-based care programs, and revenue cycle and billing strategy, including aligning initiatives with organizational goals and objectives.
• Assist in ensuring compliance with regulatory requirements and organizational policies.
• Auditing and ensuring the ambulatory division adhere to CMS and HRSA documentation auditing and billing compliance.
• Support quality assurance initiatives to enhance patient care and operational efficiency.

Performance Management-

• Monitoring and analyzing performance metrics related to quality, cost, revenue cycle, including charge capture, coding, billing and collection, identifying areas for improvement, and implementing corrective actions.

Workflow Optimization-

• Leading the development and implementation of efficient workflows for care coordination, patient engagement, and data management.
• Monitor and analyze key financial and operational metrics, net collection rates, denial rates, to identify areas and improvement.
• Work with the payors on establishing key performance metrics to meet star ratings and upside risk.
• Provide guidance to provider and billing optimization in accordance with CMS guidelines and patient severity index.

Stakeholder Engagement-

• Collaborating with providers, care teams, payers, and other stakeholders to foster alignment and drive participation in value-based care initiatives.
• Oversee payor contract strategy, analyze contract performance, and lead joint operation meetings to ensure optimal reimbursement.

Education and Training-

• Providing training and support to staff on value-based care principles, processes, and technologies. This includes training of coders and other revenue cycle staff.

Financial Performance-

• Ensuring appropriate risk adjustment and managing performance in value-based contracts to optimize financial outcomes.
• Partner with departments including, revenue cycle, finance, clinical operations, IT, Manage Care, Legal to optimize revenue capture and achieve financial and operation goals.

Technology Integration-

• Leveraging technology and data analytics to support Value Base initiatives, improve efficiency, and enhance decision-making.
• Strong understanding of value-based care models, including proven ability to lead projects, manage teams, and collaborate with diverse stakeholders including Care Coordination of Medicare Advantage, Commercial and Exchange lives to close gaps, pass quality gates and improve Star Rating, HCC level, Medical Loss Ratio.

Human Resources-

• Create and maintain an effective, collaborative, engaged, inclusive team with an emphasis on open, direct and honest communication which supports employee engagement, retention, system thinking, regional performance and market success.
• Promote and model an environment and culture of high performance and continuous improvement that values a commitment to quality through coaching and managerial oversight of staff performance and development.
• Provide and foster a positive and engaged employee environment through consistency and uniformity in application and interpretation of governing policies, practices and all terms and conditions of employment.
• Provide timely, constructive, communication and feedback consistent with Five Star Values, policies, and culture of diversity and inclusion.

This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification. Employees may be required to perform other job-related functions as necessary based on operational needs.

Qualifications

Education:

• Bachelor's degree.

Experience:

• Seven years of related experience including revenue cycle and value base billing.
• Special Training: Hierarchical Condition Category (HCC), Medical Loss Ratio (MLR), Risk Certification, Risk Auditor

Credentials:

• CPC – Certified Professional Coder (Preferred)
• CPC-1 – Certified Professional Coder Instructor (Preferred)
• CRC – Certified Risk Adjustment Coder (Preferred)
• CPMA – Certified Professional Medical Auditor (Preferred)
• CDEO – Certified Documentation Expert Outpatient (Preferred)