Director, Risk Adjustment Accuracy and Risk Mitigation

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

Southfield, MI*


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

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Competitive Compensation and Benefits Package

Overview: <p>The Director, Risk Adjustment is the strategic leadership role within SHS responsible for overseeing the optimization of risk adjustment accuracy and risk mitigation.&nbsp; As a part of the SHS Care Delivery team, the director will ensure SHS strategy and programs with partners are appropriately inclusive of risk coding implications, including driving organizational and financial competency related to Medicare risk-adjusted revenues across the SHS segment.</p> <p>Additionally, the Director, Risk Adjustment plays a critical role in overseeing the development, implementation, and execution of Medicare advantage risk adjustment strategy and ongoing submissions to CMS as well as compliance. The director will also play a critical role in collaborating for performance improvement and would be the primary point of contact within SHS for risk adjustment partnership with all enterprise partners (Advantasure, Health Care Value, Actuary, Finance, etc.).</p>
Responsibilities: <ul> <li>Oversees the integration and alignment of risk adjustment with care management and 5 Star Quality strategies, tactics and operational processes to ensure accomplishment of overall goals and objectives, and to optimize the completeness and accuracy of member health information.</li> <li>Collaborate with enterprise partners in setting overall risk score and risk adjustment revenue targets for SHS; oversee the analyzing, monitoring, reporting and forecasting key risk adjustment metrics as well as ensuring new legislation and regulations regarding Medicare risk adjustment are properly accounted for.</li> <li>Collaborate with HCV to ensure risk coding accuracy in partnership with the physician network; identify issues/gaps and develop actions to improve with HCV.</li> <li>Drive and author all SHS Blue for Life strategy development to incorporate risk adjustment opportunities in collaboration with enterprise partners</li> <li>Ensure the execution of the plan to ensure key metrics and timelines are met; serve as the SHS business sponsor for all risk adjustment initiatives funded by SHS.</li> <li>Serve on key compliance committees representing SHS for risk adjustment, will ensure a system of controls is in place for the Michigan plan related to Medicare Advantage risk adjustment activities and associated CMS revenue to: <ul> <li>meet or exceed industry averages on timeliness and accuracy of submissions</li> <li>meet plan risk adjustment revenue targets by increasing analytical detection (automated and manual) to more accurately capture a member&rsquo;s disease burden</li> <li>develop a risk adjustment oversight plan including: <ul> <li>assessment of plan risk tolerance based on industry and internal perspectives</li> <li>establishment of annual strategy for year-over-year improvement aligned with the industry</li> <li>an end-to-end improvement focus beginning with provider billing (front-end) and ending with encounter data submissions (back-end) through provider education, filtration logic and audits&nbsp;&nbsp;</li> </ul> </li> <li>oversee risk adjustment partners to ensure the strategy is executed and targets are met</li> </ul> </li> <li>Demonstrate and pass on expert knowledge in risk adjustment methodologies and industry-leading solutions and strategies to drive optimized results with enterprise partners, and raise SHS understanding and competency around risk adjustment; drive synergy with SHS segment initiatives that can impact risk coding and liaise with enterprise partners to increase impact</li> <li>Oversee the submission and corrections of all data submissions on behalf of SHS and represent SHS requirements on all audits.</li> <li>Collaborate with Advantasure, Finance/Actuarial and Analytics to develop new predictive, analytic and reporting tools to glean actionable insights into current performance and new opportunities and leverage a network of experts - internal and external - to enhance Risk Adjustment innovation and performance</li> <li>Participate in improvement of monitoring and auditing protocols to ensure internal and vendor compliance with all applicable regulations and risk adjustment data validation audits</li> <li>Leverage market insights to monitor trends and external landscape, and to inform capability strategies and customer use case scenarios</li> <li>Ensure operational integration of contractual requirements (with groups, providers, etc.) resulting in adherence to quality standards and performance expectations as required to ensure established service level agreements are met; serve as SHS key point of contact for contractual impacts of risk adjustment forecasts</li> <li>Assist in analysis of qualitative and quantitative data as it relates to risk adjustment, specifically re: missed opportunities, prevalence and suspects</li> <li>Assists in design and development of ad hoc reports and presentations for risk adjustment initiatives</li> <li>Understands intricacies of CMS Medicare model to contribute to effective strategies</li> <li>Demonstrated ability to influence cross-functional teams that lead implementation of risk adjustment interventions</li> <li>Collaborate and influence across both clinical and operational executive management, with both internal and external parties in support of risk adjustment by providing leadership, strategic direction, performance assessment and analysis, forecasting/financial planning, and management information</li> <li>Support actuarial and finance teams to ensure risk-based reporting needs are satisfied for bidding, rate setting, and revenue projections</li> </ul>
Requirements: <p><strong>EDUCATION:</strong></p> <p>Bachelor's degree in business, finance, analytics, healthcare delivery, public policy or a related field is required. A Master's degree in a related field of study is preferred.</p> <p><strong>EXPERIENCE:</strong></p> <p>Ten (10) or more years' experience in the managed care/ Payer/Provider/Health Plan/Health System Management industry or related field required. Five (5) or more years' experience in Medicare Advantage and risk adjustment is required. Risk Adjustment experience - expert status expected.&nbsp;Five (5) years management or supervisory experience in Business required.&nbsp;Five (5) or more years&rsquo; experience of progressive responsibility in a business environment with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.</p> <p>&nbsp;</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Knowledge in Risk Adjustment Factor payment methodology and familiar with other related MA programs such as HEDIS and Stars</li> <li>Experience and knowledge in compliance guidelines stated by CMS for Risk Adjustment Data Validation audits</li> <li>Knowledge in Risk Adjustment Factor payment methodology and familiar with other related MA programs such as HEDIS and Stars</li> <li>Strong analytical skills needed to prepare and analyze data to drive KPIs and process improvements within the department.</li> <li>Strong communication skills; ability to present information in a concise manner to multiple organizational levels. &nbsp;</li> <li>Superior leadership experience, particularly in cultivating a high performing team and in development and maintaining excellent relationships with key partners.</li> <li>Demonstrated track record for achieving and exceeding performance results.</li> </ul> <div id="gtx-trans" style="position: absolute; left: -39px; top: 26.7639px;">&nbsp;</div>