|Employer:||Reliance Medical Centers
|Skills:||Risk Adjustment in Health Plan or Medical Group Setting
|Required Certifications:||CPC or CRC
|Preferred Certifications:||CPC or CRC
|Required Experience:||5 to 7 years
|Preferred Experience:||5 to 7 years
|Location:||4700 Exploration Ave. Lakeland 33812, FL, US
The Medicare Risk Adjustment Program Manager will lead the
overall risk adjustment program at Reliance Medical Centers. In this role, you
will be a key strategic leader developing and executing a multi-product risk
adjustment strategy aimed at ensuring accurate diagnosis risk coding for
Reliance’s Medicare populations and achieving related revenue targets. The Medicare
Risk Adjustment Program Manager will be responsible for building out core
health plan-based risk adjustment operations, as well as developing innovative provider-based
programs, and other product-specific risk adjustment strategies. Success will
require competence in risk adjustment strategy, an ability to build and scale
risk adjustment programs, and an ability to partner effectively with provider
groups to design and implement point of care risk adjustment
- Engaging stakeholders to define a system strategy for risk
adjustment, including strategies for provider engagement, IT system
capabilities. Strategy, planning, and end-to-end oversight to ensure accurate
and complete risk adjustment.
- Develop and implement Standard Operational Procedures,
workflows, and process documentation policies for risk adjustment programs.
- Monitor risk adjustment submissions as compared to expected
revenue and proactively address gaps in data submissions and impacts to
forecasting and budgets.
- Accountable for ensuring ongoing key performance indicators
measure productivity, quality, and overall impact of the company's risk
adjustment program, including reporting KPI results on a monthly basis.
Maintains risk adjustment performance management and reporting dashboard.
- Direct the development of key analytics and data to support
Risk Adjustment financial forecasts, analysis and reporting to engage key
stakeholders and communicate program results to the organization.
- Partner with Clinical and Financial Analytics teams to define
opportunities and areas of focus to optimize risk adjustment performance across
- Develop member and provider engagement strategies, including
the use of value-based payments, incentives, and other levers to encourage
proactive risk management.
- Expert on risk adjustment models; maintains current view of
risk adjustment regulatory changes and product-specific risk model changes;
ensures appropriate operational responses to regulatory and risk adjustment
- Maximize return on investment in Risk Adjustment operations
by reducing reliance on vendors and increasing validity of data submissions.
- Maintain and oversee an effective Risk Adjustment submission
- Serve as point person for relationships with health plan
partners, including contracting and revenue management elements of risk
arrangements as well as partner oversight of ongoing performance.
- Provider site engagement and partnerships: Partner with
provider account teams to communicate risk adjustment strategies and
initiatives to provider groups; partner with provider groups to implement risk
- Internal stakeholder management: Ensures open communication
and collaboration across all relevant internal departments/positions that
intersect with risk adjustment team (Quality, Provider Relations, Product
- Specific tasks may include design and implementation of the following:
Retrospective coding program; Provider education campaigns; Provider incentive
programs; Audit and compliance programs; EMR optimization / other IT
- Bachelor’s degree in Business or Healthcare Administration or
related field required; Advanced degree preferred.
5 years of experience in managed care and risk adjustment in a health plan or
medical group setting.
- Proven ability to align cross-functional teams and drive
action to meet internal and external business and program goals and objectives.
SKILLS & ABILITIES:
- Comprehensive knowledge
of health plan activities with emphasis on Medicare or Medicaid Risk Adjustment
- Knowledge of regulatory
risk adjustment requirements and processes and audit requirements.
- Effective collaborative
and proven process improvement skills.
- Strong oral and written
communication skills; ability to interact within all levels of the organization.
- Demonstrated ability to
successfully plan, organize and manage projects, critical thinking,
problem-solving, and the analysis, interpretation, and evaluation of complex
- Ability to
conceptualize, create partnerships and facilitate change.
- Thorough knowledge of quality measures
HCC and RAF models.
- Must be mission driven, clinically
oriented, strong integrity and the ability to serve as a role model and mentor
to staff and other leaders.
- Must possess critical thinking and
problem-solving skills, strategic planning ability, project management skills
and the ability to make effective decisions.
- Strong ability to forecast healthcare
trends and lead change within the organization.
- Effective leadership skills with
development of patient focused environments.
- Advanced statistical analysis skills
- Proficient in MS Office applications such
as Word, Excel, Access, PowerPoint, and Outlook
- A license in one of the following is
- Certified Procedural Coder (CPC)
- Certified Risk Adjustment Coder (CRC)