Director of Risk Adjustment

Summary:

Location: Monarch Place; Springfield MA (MA & CT candidates only)

Schedule: Monday-Friday; fulltime; 40hrs.

Job Responsibilities:

• Develops and implements risk adjustment strategy policies and standard operating procedures
• Collaborates with physicians mid-level providers other personnel including coding experts in risk adjustment review of the medical record
• Serves as Health New Englands ambassador in the Risk Adjustment Community
• Works with industry on best practices for risk adjustment
• Manages measures and evaluates performance of Health New Englands risk adjustment vendors
• Manages all data submission requirements
• Prepares risk adjustment training programs for network physicians mid-level providers and plan personnel
• Ensures that all risk adjustment related activities are compliant with CMS/ACA and state requirements
• Serves as the risk adjustment compliance point of contact for HNEs Compliance Department
• Collaborates with data management personnel in the appropriate formatting and methodology of risk adjustment analysis and related reporting
• Develops productivity standards for risk adjustment auditing of claims or medical records
• Collaborates with the Provider Relations Department to provide coding and risk adjustment education and resource information to network providers
• Conducts educational events as necessary
• Participates in administrative teams preparation of Medicare Advantage annual bids risk adjustment determination
• Maintains expert knowledge of AMAs Coding systems including ICD-9 & 10 diagnostic CPT HCPCS codes and any national updates or revisions of medical diagnostic procedural or medical supply coding
• In collaboration with Plan management participates in regulatory review and/or audit of submitted claims risk adjustment coding
• Develops risk adjustment training materials for network providers plan personnel and prospective network providers
• Maintains working knowledge of Plan information management systems
• Collaborates with the Managed Care Data Systems personnel in the development of reports and/or customized applications utilized for risk adjustment data analysis and reporting
• Establishes business and functional requirements needed to define technology/systems platform
• Creates executive level reports and performance metrics to keep Health New England up-to-date on risk adjustment
• Manages trains coaches and develops staff

Minimally Required Education

Bachelors degree in a related field.

Preferred Education

Masters degree in healthcare administration public health health informatics population health or a related healthcare field.

Professional certification such as Certified Professional Coder (CPC) Certified Risk Adjustment Coder (CRC) or similar coding credential.

Minimally Required Experience

710 years of experience in an HMO or MCO with direct HCC risk adjustment experience.

At least 2 years of management experience.

Experience with medical claims review coding or utilization management.

Knowledge of CMS risk adjustment methodologies and ICD-9/ICD-10 coding.

Preferred Experience

Experience in population health analytics and risk adjustment strategy.

Experience across multiple lines of business including ACA Medicare Advantage (MA) and Medicaid models.

Certification:

Ability to obtain relevant coding or risk adjustment certification within a reasonable timeframe if not already held.

Education:

Certifications:

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidates relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

Equal Employment Opportunity Employer