The Program Manager, Risk Adjustment is responsible for managing and overseeing the end-to-end execution of Risk Adjustment Program. The Program Manager will partner closely with provider network managers and clinical leadership in engaging the physician network to assess members for their significant and chronic diseases as well as ensuring HEDIS quality gaps data is appropriately submitted. This person will work across multiple operation teams to develop or improve systems, processes and tools that will help with the identification of diseases, assessment of the diseases and care gaps with proper documentation to ensure accurate submission of information to payer entities. The Program Manager must also be adept with developing tactics to meet program goals and metrics.
Essential Job Functions:
- Implements and manages the strategic plans for the risk adjustment program, including working with leadership on approaches to structure an effective risk adjustment programs in the local market.
- Continually assesses the tactical processes to achieve program objectives and putting in program changes where needed
- Ensures accurate and complete data capture in all programs; this includes but is not limited to: retrospective and prospective chart reviews and assessment program
- Create, reviews and maintains operational workflows that are efficient and effective
- Work with medical leadership to enhance electronic health record systems and tools for physician network to use
- Successfully interacts with physicians and physician office staff to engage in programs developed
- Oversees claims/encounter data collection, processing, submission and data reconciliation efforts with provider network and health plans ensuring that collected data is processed all the way to CMS’s RAPS system as well as EDPS system.
- Develops and implements approaches to measure the effectiveness of physician specific initiatives for improving risk score accuracy.
- Maintains expert knowledge of the risk adjustment process, including regulatory changes impacting the program
- Ensures company approved compliance programs and P&Ps are upheld across the market
- Collaborates across the company and with vendors to help ensure the integration and alignment of risk adjustment strategies ·
- Leads staff assigned to risk adjustment; provides guidance and engagement of staff; and builds effective teams (both internally and with vendors) to achieve established goals and within established budgets
- Demonstrates the ability to lead and influence others positively to achieve desired goals.
Other Job Functions:
- Understand, adhere to, and implement the Company’s policies and procedures.
- Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
- Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
- Engage in excellent communication which includes listening attentively and speaking professionally.
- Set and complete challenging goals.
- Demonstrate attention to detail and accuracy in work product.
- Three or more years of experience in one or more of the following: Risk Adjustment, Quality/HEDIS, Health Care Finance, Health Care Compliance and/or General Health Plan Operations
- Demonstrated experience in managing a high-volume workload and meeting tight deadlines
- Ability to maintain confidential information
- Experience working as part of a team to accomplish a shared objective
- Working knowledge of Medicare Advantage, Part C & D laws and regulations
- Familiarity with ICD-10
- Microsoft Excel proficiency; Microsoft Access preferred
- Bachelor’s degree (B.A.) from four-year College or university; or three years related experience and/or training; or equivalent combination of education and experience.
Skills and Abilities:
Language Skills: Strong communication skills both written and verbal to work with multiple internal and external clients in a fast-paced environment Mathematical Skills: Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Reasoning Ability: Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems. Computer Skills: Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint)