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Director of Risk Adjustment
4 months ago
**Essential Responsibilities:**
Manage end-to-end revenue optimization initiatives for PacificSource Medicare Advantage plans and Commercial Exchange plans. Lead cross functional revenue teams. Oversee contracted vendor activities and overall performance in the areas of risk adjustment, coding improvement, chart review, and reconciliation. Develop and direct implementation of Risk Adjustment Strategic Plan in cooperation with key business partners including provider medical groups, coding, information systems, risk adjustment team, and finance department. Develop and oversee implementation annual initiatives for risk adjustment and revenue management initiatives to support the overall strategic goals. Ensure risk adjustment and revenue enhancement activities are in strong alignment with PacificSource values, positive provider engagement, and improving care to our members. Develop and maintain best practice member accounting and CMS reconciliation processes. Interface with Pharmacy Benefits Manager vendor to ensure accurate Medicare Part D reconciliation procedures. Function as key liaison and provide support on revenue management initiatives, best practice principles around contract negotiations efforts, and lead policy/process to affect organizational change to improve efficiency and profitability. Continuously monitor and learn about market trends and methods other companies are using to optimize revenue performance and manage risk scores. Manage vendor relations and activities to meet department goals. Develop and implement business plan to supplement the vendors revenue management activities using internal staff. Oversee internal and external stakeholders ensuring coding is accurate and correct. Oversee extracting and collecting diagnosis data from claims systems, submitting this data in the form of Medicare Risk Adjustment Processing System (RAPS) files to CMS in a timely manner, and oversee the RAPS record error correction processes. Perform projections, analysis and monitoring for both complex risk adjustment projects and ongoing operations. Monitor and analyze risk score trends. Work with IT and Actuarial staff to reconcile data with Medicare financials, forecast risk adjustment factors, and model impacts of potential payment changes. Responsible for oversight, management, development, implementation, and communication of department programs. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports. Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed. Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities. Actively participate as a key team member in Manager/Supervisor meetings. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
**Supporting Responsibilities:**
Interact with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, Marketing & Sales, IT, AUA, and Compliance. Coordinate business activities by maintaining collaborative partnerships with key departments. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy. Actively participate as a key team member in manager/supervisor meetings. Assists in annual Medicare Bid process. Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned.
**SUCCESS PROFILE**
**Work Experience:** 5 years in healthcare and 3 years risk adjustment experience. Knowledge of CMS risk adjustment and pricing mechanics.
**Education, Certificates, Licenses:** Bachelors Degree in related field required.
**Knowledge:** Advanced knowledge of CMS regulations governing Medicare reimbursement. Demonstrated leadership in program development and management; 3 years cross-functional management experience.
**Physical Requirements:**
Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive
motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.**Disclaimer:**
This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.locationPortland, ORlocationPortland, ORPacificSource is anything but a typical health insurance company. Founded in 1933, were an independent, not-for-profit organization that puts our members, and their communities firstacross Idaho, Oregon, Montana, and Washington.
It's our 1,600+ employees who make it happen: promoting health equity and partnering with providers to deliver better access to optimal, affordable care. *So yes*, with PacificSource, you get to do great things. In our effort to put members firstmore than 500,000 of theminitiative, commitment, and hard work are supported and rewarded with excellent benefits, competitive wages, and opportunities for personal growth and advancement.
**Benefits:**
Medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account.
We love our common purpose. Empowerment, flexibility, and sharing success make for a great place to work. Heres what else we feel good about:
* A mission with a real sense of shared values
* Competitive wages and outstanding benefits, including telecommuting
* Opportunities for learning development and career advancement
* Organizational leadership style rooted in servant and transformational leadership
* A commitment to support the communities we serve
* A belief in the importance of work-life balance
PacificSource is an equal opportunity employer and a company that loves helping people. We work with our employees to understand their goals, and provide training, individual development, and career advancement opportunities to help them achieve just that. In the past nine months alone, we have had 164 internal promotions. That means 34.5% of our open positions have been sourced internally.
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