Resp & Qualifications
PURPOSE:
The Director, Risk Adjustment oversees the outcomes and operations of risk adjustment across the organization within Medicare Advantage, Medicaid & ACA markets. 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 people leader 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 at least two days a 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, RADV, Encounter & ACA EDGE 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:
- Masters 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: $140,640 - $261,063
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
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: www.carefirst.com/careers
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
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