Program Manager-Risk Adjustment

This job requires an experienced detail-oriented and highly analytical person to lead, manage and oversee risk adjustment programs and effectively understand and implement vendor programs and ensure contract SLAs and deliverables are met.

Location: this position has preference to based in hybrid work location (onsite and WFH). There may be opportunity for fully remote within a mutually acceptable location. #LI-Hybrid

To be considered for this opportunity, you have:

Experience: 5 years’ Medical Coding, Program Management, or Health Industry experience

Education: Bachelor’s Degree or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)

Certifications/Licenses: Preferred qualifications:

• Certified Professional Coder Certification (CPC)
• Clinical Research Coordinator (CRC)

We'd also love it if you had:

• Local presence in Idaho
• Experience in healthcare industry
• Business Continuity Certification Preferred (CBCP, MBCP, BCCE, etc.)

In this role, we will ask you to:

• Monitor and analyze program performance metrics and identify trends to enhance overall accuracy of risk programs. Including report creation and monitoring of KPIs.
• Stay current with industry and governmental regulations, guidance and best practices related to risk adjustment, healthcare compliance and coding accuracy.
• Develop training materials and educational programs to enhance the understating of risk adjustment practices among internal and external stakeholders including but not limited to brokers, members, Care Managers, Customer Service, executive leaderships, Compliance, Legal, and other internal departments. Create and revise policies, procedures, and protocols relevant to program activities.
• Identifies opportunities to reduce risk in audits and other government reviews of risk adjustment programs and practices.
• Work closely with Legal and Compliance on wording used in risk adjustment communication.
• Identifies issues determined to impact risk adjustment and works with the affected teams and vendor partners to resolve them in a manner that complies with internal and external governing rules and regulations.
• Supports audits to ensure complete and accurate coding and reporting of documented member chronic health conditions.
• Participate in the development and implementation of innovative solutions to optimize risk adjustment processes.
• Serve as a risk adjustment coding subject matter expert.
• Keep thorough documentation of processes and steps taken for audit purposes. This includes, but not limited to program implementation guides.
• Present at risk adjustment related conferences, seminars, meetings, and other speaking engagements.
• Collaborate with cross-functional teams, including, Provider Engagement, Risk Adjustment Coders, Data Analysts, vendors, Quality/HEDIS, Healthcare Operations, Compliance, Legal, Marketing, Corporate Communications, IT and Procurement to streamline processes, ensure compliant timely execution and to support data integrity.
• Perform other duties and responsibilities as assigned.

As of the date of this posting, a good faith estimate of the current pay range is $86,650 to $129,974. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).

The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.