Director, Risk Adjustment - Baltimore, United States - Behavioral Health Tech

Behavioral Health Tech Baltimore, United States

2 weeks ago

Description

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Director, Risk Adjustment (Hybrid)

Baltimore, MD

Senior +1 · Full time

Posted 7 days ago

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Director, Risk Adjustment (Hybrid)

Job ID:

18733

Job Function:
Audit & Legal

Location:
Baltimore, MD, United States

Campus:
MD-Baltimore-Canton Crossing

Career Band:

BDC

Status:
Full-Time

Resp & Qualifications

PURPOSE:

The Risk Adjustment Director oversees the outcomes and operations of risk adjustment across the organization within all the assigned products.

The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key function, overseeing enterprise risk adjustment while identifying areas of improvements and implementing processes.

In addition, the Director evaluates, modifies, maintains & executes the end-to-end Risk Adjustment/Risk Adjustment Data Validation (RADV) strategies & actions across all the assigned populations and products.

This role collaborates and partners with enterprise stakeholders across the organization.

We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model.

The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

Define and establish standards and frameworks for Risk Adjustments related to KPIs, OKRs, ROI, action plans, progress and risks on all levels within CareFirst teams.

Establish definitions for key data elements to meet industry standards and assess risks adjustments across all relevant risk domains.

Develop and manage tracking tools, dashboards, and metrics for monitoring the progress of the Risk Adjustment Program across all lines of business.

Drives member and provider intervention close Risk Adjustment gaps.

Support the development and delivery of enterprise-wide training and awareness materials that educate associates and leadership on best practices, pervasive operational risk adjustment issues, risk adjustment tools and processes, and lessons learned.

Oversee the enterprise risk adjustment process, including impact analysis and actions related to risk adjustment-related regulatory changes. Drive to implement appropriate changes necessary across CareFirst teams and processes to impact business outcomes. Collaborate across the eco-system such as CMS, State & BCBSA to drive necessary regulatory improvements.

Ensure that risk adjustment activities and decisions are in alignment with strategic goals and objectives, and are executed in consideration of the impact on the organization's goals.

Establish standards for and provide advisory support in the completion of Risk Adjustment processes, as well as govern, support, and mentor associates within Risk Adjustment analytics, prospective & retrospective strategies, regulatory submissions.

Develop and implement action plans related to prospective, retrospective, and regulatory data submissions affecting assigned products and plans, including detailed work plans, issue logs, and progress reports.

Serve as an SME to guide CareFirst's VP of Enterprise Quality & Risk Adjustment, Finance, Actuarial, and P/L owners of Lines of business in bid filings, regulatory filings, and financial performance planning & reporting.

Forge relationships with business owners across the enterprise to understand issues and concerns, provide the correct level of support, and proactively identify risk priorities, control efficiency and effectiveness, and process improvement opportunities.

Set high expectations of significant influence on other departments/divisions for all process improvements to support objectives with cross-functional impacts. Drive commitment and continuous personal improvement, self-confidence, insight, judgment, integrity, ethics, and responsiveness, timeliness, flexibility and adaptability.

Manage departmental, team and project performance by mentoring and coaching, as well as establishing and monitoring goals, timelines/milestones, outcomes and as necessary corrective action measures.

The affected categories of persons are:
direct and indirect reports and vendors. Prioritize work in alignment with Risk Adjustment strategy, business goals, organizational strategies and objectives.

SUPERVISORY RESPONSIBILITY:
This position manages people.

QUALIFICATIONS:

Education Level:

Bachelor's Degree in Health Care Administration, Public & Population Health, Finance, Business Analytics, or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience:
8 years of progressive responsibility in healthcare.
3 years specifically in risk adjustment environment, within healthcare insurance within Government Programs (MA & Medicaid) & ACA.

Preferred Qualifications:
Master's in business administration, Master's in Health Administration or Master's in Public or Population health.
Knowledge, Skills and Abilities (KSAs)
Knowledge and experience across all regulatory guidelines on Risk Adjustment.

Experience successfully planning and leading presentations to physicians, internal stakeholders, and C-suite with a focus on coding data and analytics.

Experienced with effective physician/provider collaborative training to support workflow adjustments to improve clinical coding quality.

Successful completion of a Coding Certificate program from an accredited organization (i.e., CPC, CRC, CPMA from AAPC, or CCS, CCS-P from AHIMA).

Strong leadership skills, Risk Adjustment financial acumen, vendor oversight skills & an experience in payer, provider & industry collaboration.
Ability to work in a fast-paced environment and drive consistent actions across a matrixed environment.

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.

Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range:
$132,800 - $246,510

Salary Range Disclaimer
Salary will be based on education, location, experience, certifications, etc.

In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).

Department

Department:
Med Adv MD - STARS/Risk Adjust)
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.

It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply
Please visit our website to apply:
Federal Disc/Physical Demand

Note:

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-NH2
Carefirst

CareFirst is a not-for-profit, non-stock health services company.

Size:
employees

Year Founded:

1934

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