Leads the development, analysis and reporting of key risk adjustment metrics, as well as oversees analyses of new legislation and regulations regarding Risk Adjustment and assessing the impact of any changes to the programs. Maximizes revenue strategies for VNS Health Plans. Coordinates multiple cross functional activities and projects related to risk adjustment across all departments as well as interactions with external vendors. Oversees the performance of the person(s) and vendors in charge of chart audits, home visit assessments and the performance of internal resources devoted to the Hierarchical Condition Category/Risk Adjustment Factor (HCC/RAF) efforts. Collaborates with the data science and business intelligence teams to determine potential data analytics initiatives with the focus on improving operations to improve risk score accuracy. Works under general direction.

$193,600.00 - $258,200.00 Annual

What We Provide

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Leads various cross functional initiatives between VNS Health Plans Services departments, including but not limited to Finance, Service Ops, Medical Management, Business Intelligence, Provider Relations, Compliance and Quality. Maintains relationships with external vendors and provides ongoing support to manage initiatives across Risk Adjustment.
• Builds strategies to create inhouse risk management initiatives and capabilities thus reducing reliance on vendors and increasing accuracy of data submissions.
• Develops and maintains risk adjustment performance management dashboard, in partnership with Business Intelligence and Analytics team.
• Develops and maintains an expert level of knowledge of Medicare and risk-based reimbursement methodologies. Keeps up to date on industry trends and writes reports on evolving payment policies. Monitors CMS regulations related to risk score submissions and reimbursement.
• Oversees overall coding strategy. Ensures vendor accountability for performance and oversees chart review operations to close HCC gaps.
• Oversees and verifies the submission of federal and state data filings, report delivery to and from vendors and providers, and ensures that data is transmitted completely, correctly, and on time.
• Identifies and prioritizes risk adjustment opportunities and identifies resources as needed.
• Develops and leads various initiatives for risk score optimization. Assists reporting and analytics team in building operational dashboards that can be used to monitor progress across various initiatives.
• Collaborates with Quality Improvement (QI) department on Stars and/or or other initiatives.
• Develops and audits Risk Assessment Data Validation (RADV) readiness plan and monitoring program.
• Collaborates with internal and external experts to develop metric-supported strategies that improve revenue and decrease risk exposure.
• Leads the internal and external risk adjustment data validations, including contingency planning.
• Performs all duties inherent in a senior managerial role. Approves staff training, hiring, promotions, terminations, and salary actions. Prepares and ensures adherence to the department budget.
• Participates in special projects and performs other duties as assigned.

Education:
Bachelor's Degree in Business Administration, Finance, Health Care Administration, or other related field required
Master's Degree in Business, Health Administration, Health Policy or related discipline preferred

Work Experience:
Minimum eight years of progressively responsible experience in health insurance industry with specific experience in risk adjustment required
Demonstrated working knowledge of Medicare Risk Adjustment methodology, Medicare payment policies, coding and documentation practices, and process improvement and optimization techniques required
Strong understanding of healthcare operations,encounter and risk adjustment data and the ability to analyze, identify gaps and recommend strategic initiatives for revenue maximization required
Operational knowledge of provider relations, claims, and medical management required