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Director, Risk Adjustment - Hybrid

Summary of Job

Develop and execute a comprehensive annual Risk Adjustment strategy that supports the Company strategies and improves the quality of care delivered to Emblem members, and to ensure the plan reimbursement accurately reflects the clinical diagnosis of our Medicare, Medicaid, and Affordable Care Act (ACA) members. Develop and execute an annual Provider Risk Adjustment strategy to improve the accuracy of their diagnosis coding through education and engagement of our risk adjustment programs, reimbursement models and the ongoing development/ enhancement of support capabilities that complement their clinical practice model. Prepare and present provider risk adjustment results at all Emblem joint operating committee meetings and monthly risk adjustment operational meetings. Select and manage best-in-class risk adjustment vendors to drive continual improvement in the accuracy of diagnosis coding for Medicare, Medicaid, and ACA members. Manage the ongoing performance, compliance and return on investment for each risk adjustment vendor. Create and maintain a capabilities framework that is member and provider centric and is appropriate given for the clinical and demographic dynamics of members in risk adjusted products. Manage the creation and timely production of risk adjustment operation and financial performance reports for all risk adjustment programs, and lead monthly risk adjustment operation meetings with Emblem leaders for VP, Risk Adjustment. Be a strategic partner with the Actuarial, Quality and Product teams to enhance risk adjustment interventions and results. Establish enterprise-wide monitoring and reconciliation reports to ensure that risk adjustment vendor results are accurately, timely and completely submitted to government entities.

Responsibilities

Develop, manage, and improve all retrospective risk adjustment programs to retrospectively identify, retrieve, code and submit diagnostic information from providers on EmblemHealth members enrolled in Medicare, Medicaid, and ACA products; manage all vendor relationships that support these retrospective activities.
Develop, manage, and improve prospective and concurrent risk adjustment programs to ensure accurate capture and reporting of diagnostic information for EmblemHealth members enrolled in Medicare, Medicaid and ACA products.
Work with risk adjustment vendors and providers to execute in office assessment programs through which they 1) identify members based on clinical needs and quality gaps, 2) outreach to patients to encourage them to make office visits to receive services and 3) completely and accurately document all diagnostic conditions.
Manage the In-Home Assessment risk adjustment vendor program.
Manage team completing revenue management opportunities for Medicaid, Medicare and Health Exchange products which includes identification of risk score opportunities, suspects, analysis and tracking of performance and attribution of interventions.
Direct EmblemHealth provider relationship and engagement risk adjustment activities.
Direct interaction with the CFO, CEO and other physician leaders of ACPNY groups and other large, sophisticated medical groups to integrate our programs into the provider’s operations.
Analyze data to identify submission trends against historic data and membership changes and recommend opportunities to improve accuracy and completeness of all government submissions.
Collaborate with EmblemHealth medical management, quality, marketing & sales and network departments to identify opportunities to achieve efficiencies and improve effectiveness of risk adjustment activities by integrating both prospective and retrospective programs with care management, CMS Stars, Medicaid and Health Exchange quality programs, sales outreach and provider contracting.

Qualifications

Bachelor’s Degree in Healthcare, Finance, Business, or related field (Required); Master’s degree (Preferred)
10 – 12+ years of relevant, professional work experience (Required)
Experience in healthcare, plan or provider operations and relations or related experience (Required)
Leadership experience - including staff and process management experience (Required)
Risk adjustment knowledge and expertise across Medicare, Medicaid, and Commercial exchange (Required)
Capacity to multi-task at high detail-oriented level (Required)
Strong communication skills (verbal, written, presentation, interpersonal) including executive leaders meeting experience (Required)
Strong working knowledge of MS Office - Word, Excel, PowerPoint, Access, Outlook (Required)
Strong analytical and logical skills paired with strong attention to detail (Required)

Additional Information