Chief Risk Adjustment Officer

1 week ago

Denver, Colorado, United States Physician Health Partners Full time

The Senior Vice President of Risk Management plays a pivotal role in overseeing the strategic direction and execution of various initiatives related to Risk Adjustment Programs. This position is essential for the comprehensive development, supervision, and enhancement of Medicare adjustment strategies and operations.

  • KEY RESPONSIBILITIES:
  • Lead the integration, administration, and execution of the Medicare Risk Adjustment Program throughout the organization.
  • Manage and finalize all components of Risk Adjustment projects and initiatives.
  • Supervise daily operational activities related to risk adjustment:
  • Oversee coding team functions, providing guidance on coding challenges.
  • Ensure coding processes align with medical necessity for procedures.
  • Engage in CMS user group discussions and regional conferences.
  • Maintain quality oversight for accurate and timely data entry.
  • Analyze data to identify patterns and trends, uncovering opportunities for documentation enhancement.
  • Ensure documentation adheres to CMS regulations and aligns with organizational objectives.
  • Utilize predictive analytics and insights from analytic teams to discover opportunities and craft innovative interventions for improved care management.
  • Continuously enhance the quality assurance program to monitor, audit, and elevate the quality of provider medical record documentation and coding practices.
  • Identify and propose innovative solutions for improving clinical documentation collection and recording.
  • Educate stakeholders on marketplace changes and regulatory updates.
  • Oversee relationships with third-party entities that support risk adjustment functions.
  • Manage CMS audit and data validation processes.
  • Foster collaborative partnerships with Finance, Clinical Operations, and other departments to meet objectives.
  • Adhere to HIPAA regulations, Diversity Principles, Corporate Integrity, and Compliance Program policies.

EDUCATIONAL REQUIREMENTS:

  • Master's Degree preferred, ideally in healthcare administration, business, or a related field.

PROFESSIONAL EXPERIENCE:

  • Minimum Qualifications:
  • 10 years of experience in healthcare, managed care, health insurance, or strategic consulting.
  • 6 years of leadership and management experience.
  • 4 years of experience in medical record review, case management, utilization management, managed care, Home Health, QA Review, or HEDIS review.
  • 4 years of experience with healthcare payment and coding methodologies (e.g., ICD-10, CPT, DRG, and HCC coding).
  • Proven ability to influence various functional leaders within a matrix organization.
  • Strong organizational and project management capabilities.
  • Exceptional oral and written communication skills.
  • Proficient in facilitating meetings, discussions, and consensus-building processes.
  • Experience with Microsoft Word, Excel, and PowerPoint.
  • Ability to work independently and manage tight deadlines.
  • Experience collaborating with clinicians, payers, vendors, and other key stakeholders.
  • Familiarity with quality-based and/or risk-based health insurance contracts.

KNOWLEDGE, SKILLS, AND ABILITIES:

  • Excellent interpersonal and communication skills, including negotiation and conflict resolution.
  • Demonstrated creativity and adaptability in high-pressure environments.
  • Strong organizational skills.
  • Innovative problem-solving abilities.
  • Capacity to work collaboratively across various entities and disciplines, fostering teamwork.
  • Comprehensive knowledge of modern healthcare administration practices within a managed care context.
  • Adept at developing and analyzing options, recommending solutions, and addressing complex issues.
  • Effective organizational, planning, and project management skills.
  • Experience in delivering financial and programmatic presentations.
  • Ability to function independently while managing multiple projects simultaneously.
  • Self-awareness regarding personal strengths and weaknesses, with a commitment to professional growth.
  • Dedication to quality and excellence in all endeavors.
  • Capability to implement change positively and thoughtfully.
  • Skill in setting goals and priorities effectively.
  • Inspires confidence and encourages appropriate risk-taking while achieving high standards.
  • Proactive in trying innovative ideas.
  • Positive attitude coupled with urgency, sound judgment, and decisiveness.
  • Ability to persuade and build consensus.
  • Strong communication skills in both written and verbal formats, fostering trust and understanding.
  • Willingness to travel for meetings as required.

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