Company :

Job Description :

JOB SUMMARY

This job, is the strategic leadership role that, establishes and drives overall strategic direction, programs and services in collaboration with VP of Revenue Program Management in support of governmental products where Risk Adjustment methodologies apply. Functions as the business owner of the risk adjustment process as well as identifying and applying best practices and processes to ensure efficacy and accuracy of risk adjustment programs. Identifies and recommends both strategic and tactical improvements to these processes, and ensures compliance to all applicable laws, guidance, and regulations. Establishes metrics across RPM programs to monitor performance and drives optimal and compliant outcomes by analyzing, monitoring, forecasting and planning key risk adjustment initiatives and identifying improvement opportunities. Functions as the primary advisor of strategic direction on risk adjustment and collaborates and communicates with both clinical and operational executive management and external vendor partners.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plan, organize, staff, direct and control the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
• Support VP Revenue Program Management in identifying, promoting and executing process improvement strategies and programs to ensure maximum efficiencies, accuracy and completeness of member health information.
• Develop and oversee implementation of risk adjustment programs and processes for the collection, submission, and reconciliation of government required data in full compliance with all applicable laws, guidance, and regulations. Ensure member and product risk revenue profiles levels are accurate and risk revenue targets are achieved to ensure the company’s government revenue retention and growth.
• Evaluate, proactively monitor and report on all revenue generation processes and programs for government risk based revenue products and its effectiveness.
• Maintain expert knowledge of principles and methods of planning, directing and maintaining compliance with risk adjustment standards. Effectively mitigate risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties.
• Collaborate at advanced levels and maintain influence across the enterprise, utilizing cross-functional, matrixed relationships. Oversees the integration and alignment of risk adjustment, STARS/HEDIS and care management strategies, tactics and operational processes, and demonstrating ability to partner, inspire and motivate across organization structure.
• Function as the management lead in the identification, evaluation, and management of risk adjustment-related vendors which includes directing the preparation of RFPs, evaluation of responses, selection of vendors, and execution of pilot programs or proof-of-concept efforts. Negotiate with vendors on behalf of the company and works with procurement, legal, and other stakeholders to execute MSAs, BAAs, contracts, and SOWs with strong compliance and financial protections.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Business, Finance, Health Administration, or related field

Substitutions

• 6 years in Risk Revenue or related field

Preferred

• Master's Degree in Business, Finance, Health Administration, or related field

EXPERIENCE

Required

• 10 years of experience

To Include

• 5 years in Health Insurance or related field
• 5 years in direct Management
• 3 - 5 years leading large scale, cross divisional, multi-year projects/programs

Preferred

• 3 years in Managed Care
• 3 years in Budget Administration
• Experience in leading Medicare Advantage risk adjustment strategies

LICENSES OR CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Proven leadership experience in functional and matrix aligned organizations
• Strong communication and interpersonal skills
• Outstanding organizational and written communication skills
• Excellent interpersonal and oral communication skills
• Strong leadership skills, and ability to work well at all levels within the organization
• Strong commitment to continuous process improvement and effective change execution
• Strong analytic skills and business acumen
• Results oriented
• Ability to build strong culture of collaboration and teamwork

Languages (Other than English)
None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Basd

Teaches/Trains others regularly

Occasionally

Travels regularly from the office to various work sites or from site-to-site Does Not Apply

Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply

Physical Work Site Required

Yes

Lifting: up to 10 pounds

Occasionally

Lifting: 10 to 25 pounds

Does Not Apply

Lifting: 25 to 50 pounds

Does Not Apply

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies .

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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