Interim VP, Risk Adjustment

3 weeks ago

Pittsburgh, United States GSSR Inc Full time
Job DescriptionJob Description

Project Summary: Client is seeking a strategic leaderresponsible for ensuring the complete and accurate documentation of members'disease burden. This leader establishes and drives the health plan's strategyand organizational competency related to risk adjustment across all lines ofbusiness.

Required Skills:

  • 8-11 years Risk Adjustment in Health Plan environment, focus on Medicare Advantage, however, experience in other LOBs (Medicaid, Exchange, and Commercial)
  • Oversees health plans risk adjustment program for all lines of business (Medicare, Medicaid, Exchange, Commercial), including development and execution of the risk adjustment strategy. Focus on Medicare Advantage business.
  • Collaborates with stakeholders across the organization (including market leaders, Chief Actuary, Chief Financial Officer, Medical Directors, Quality, Care Management, Information Technology, Product Development, and Provider Network Management) to achieve enterprise goals.

Responsibilities:

  • Designs, develops, and implements risk adjustment strategies and tactics including both prospective efforts to drive risk score completeness and accuracy, as well as retrospective strategies.
  • Evaluates program performance against targets for risk score accuracy and tightly manages vendor performance to ensure program integrity. Develops and monitors management reports that measure expected service levels, data and processing quality, and production volumes of risk adjustment initiatives and programs and operations. Identifies and addresses process improvement opportunities.
  • Establishes a risk based approach for developing initiatives designed to mitigate RADV risk and ensure risk score accuracy. Ensures compliance with administrative and legal requirements concerning risk adjustment data submissions and processes.
  • Engages with key provider groups on risk adjustment initiatives and provides risk adjustment data and reporting to support value based contracts.
  • Monitors CMS and MDHHS systems, guidance and notices, and oversees the implementation of new Medicare Advantage, Medicaid, and ACA risk adjustment requirements consistent with CMS and MDHHS regulations.
  • Recruits, develops and motivates a high performing team, and provides career and skill development for the team. Motivates and inspires the team and others involved in the risk adjustment initiative to commit to ever increasing standards of excellence, service, results orientation, and quality.


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