Vice President, Risk Adjustment

1 month ago

Oakland, California, United States Blue Shield of CA Full time

Your Role

The Vice President, Risk Adjustment Strategy and Program Management is responsible for leading the enterprise risk adjustment strategy by effectively designing and coordinating all aspects of the organization's risk adjustment program. This individual leads the development and implementation of programs and initiatives to improve coding accuracy, including provider education and tools; retrospective and prospective member and provider initiatives; vendor management; accountability for preparation for and management of the Center for Medicare and Medicaid Services (CMS) auditing processes; management of encounter data processes; and management of applicable state and federal guidance. The Vice President works in close partnership with many aspects of the organization and is central to leading a comprehensive and seamless risk adjustment program throughout Blue Shield of California and where all applicable lines of business including Medicare Advantage (MAPD), individual, small group, Medi-Cal, CalPERS, and any other large accounts and private exchanges that utilize risk adjustment in the premium setting process.

Your Work

In this role, you will:

  • Be accountable for end-to-end risk adjustment for all relevant lines of business. Directs and oversees risk adjustment strategy, including prospective and retrospective chart review and procurement processes; internal and external audit preparation and risk mitigation; data analysis to support risk revenue accruals; Center for Medicare and Medicaid Services (CMS) encounter data submissions for Blue Shield of California to ensure complete and accurate risk capture. This requires seamless integration with multiple service functions (e.g. actuary, clinical quality, and audit, vendor management, project management, capability development, and provider education). Establishes goals and policies with the directors of operational and analytics teams, continually challenges leaders and their teams to evaluate processes and capabilities to further improve efficiencies and evaluate performance of the risk adjustment program.
  • Provide strategic leadership to influence corporate strategy relative to Blue Shield of California's risk adjustment strategies and continues to develop and evolve coding accuracy in concert with industry and federal regulations (CMS). Collaborate with network leadership; and supports vendor / provider partnerships - including data / information sharing, reporting, tools, and resources - to drive more accurate risk capture and revenue program management. Drives strategic improvements, maintains relationships with internal and external stakeholder to ensure a cohesive risk adjustment program that is member and provider focused.
  • Be accountable for developing prospective and retrospective risk adjustment review processes that are in compliance with all government regulations to drive accurate coding for all Lines of Business in support of accurate risk capture; efforts will serve in partnership with Blue Shield of California Stars, Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Healthcare Effectiveness Data Information Set (HEDIS) quality programs
  • Manage universal relationship strategy for vendor relationships which includes performance management and process improvements to increase quality and efficiencies for risk adjustment strategies and initiatives.
  • Oversee program governance and management, including evaluating existing operational metrics, and developing new metrics as necessary, to better assess the performance of the organization in achieving risk adjustment coding accuracy and mitigating compliance risks.
  • Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing the Risk Score of the risk adjustment programs through Member and Provider Engagement initiatives.
  • Collaborate and coordinate with internal and external stakeholders to work through barriers, manage multiple competing priorities and resources, and influences activity both inside and outside of direct accountability.
  • Oversee cross functional risk adjustment support teams, which supports ad hoc and supplemental data and reporting needs to support all the operational units i.e. Prospective (member outreach and provider engagement), Retrospective (medical record review and provider auditing), and Operations units, including, but not limited to: quickly and easily organizing large data sets, quickly and easily creating, automating, and documenting operational processes for Retrospective and Prospective Risk Adjustment, reconciling large data sets and/or reports from disparate sources (e.g., reconcile vendor reports with internal data), for Business Intelligence (BI) tools for risk adjustment interventions, updating data sets into BI tools, or otherwise extracting and filtering multiple files for campaign purposes, and critically reviewing the outputs from the tools, and actively participating in each operating team's strategic and tactical planning.

Your Knowledge and Experience

  • Bachelors degree in Health Administration, Business, Finance or related field; Master's degree preferred
  • Minimum ten (10) years' experience in clinical, quality, provider engagement and/risk adjustment, with at least 5 years in a senior leadership role
  • Demonstrated knowledge of Center for Medicare and Medicaid Services (CMS) practices, policies, and regulations
  • In-depth knowledge of Medicare Advantage, Affordable Care Act (ACA), and other government risk adjustment processes and regulations
  • Experience with strategy development, execution, planning, and management of high priority/high visibility projects related to corporate enterprise efforts
  • Proven track record of developing and implementing successful risk adjustment processes and regulations
  • Excellent leadership and team management abilities with a history of developing high performing teams
  • Effective communication and interpersonal skills, with the ability to influence stakeholders at all levels
  • Experience with risk adjustment software and analytics tools
  • Process improvement knowledge and experience
  • Comprehensive knowledge of payer environment and healthcare systems
  • Strong financial management, organizational, negotiation, analytic, problem solving and management skills, with the ability to interpret complex data
  • Demonstrated track record of driving large-scale business change, particularly in a matrix environment

The pay range for this role is: $ $250,000.00 to $310,000.00 for California.

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

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