The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

We truly value our staff and further acknowledge their contributions by offering:

• Employee and family health coverage
• Competitive salaries
• Employer contributed pension plan
• Generous paid time off
• Tuition reimbursement
• 403(b) retirement plan
• ...and More!

MJHS companies are qualified employers under the Federal Governments Paid Student Loan Forgiveness Program (PSLF)

The AVP of Risk Adjustment is responsible for the development, implementation, and execution of the strategic risk adjustment plan for Medicare line of business insuring its alignment with the financial goals and objectives of the company. The AVP of Risk Adjustment is responsible for developing and enhancing relationships with providers and the risk adjustment community. The incumbent will serve as a subject matter expert in risk adjustment. The AVP will establish risk adjustment policies and procedures, as well as provide leadership to the Risk Population Management Department. The AVP is expected to provide periodic reports and dashboards to the Executive Leadership Team.

• Develops and implements risk adjustment strategy, policies and standard operating procedures.
• Collaborates with physicians, mid-level providers, other personnel, including coding experts, in risk adjustment review of the medical record.
• Develops productivity standards for risk adjustment auditing of claims or medical record.
• Educates on best practices for risk adjustment and optimization as well as conducts educational events.
• Collaborates with the Provider Relations Department to provide coding and risk adjustment education and resource information to providers.
• Develops risk adjustment training materials for providers, plan personnel and prospective network providers.
• Manages, measures, and evaluates performance of risk adjustment vendors and providers.
• Coordinates all data submission requirements for EDPS, IHAs and unlinked chart submission.
• Prepares risk adjustment training programs for physicians, mid-level providers, and plan personnel.
• Ensures that all risk adjustment related activities are compliant with CMS and state requirements.
• Manages the plan-to-plan reimbursement process.
• Collaborates with Health Economics data management personnel in the appropriate formatting and methodology of risk adjustment analysis and related reporting.
• Collaborates with the Health Economics Managed Care Data Systems personnel in the development of reports and/or customized applications utilized for risk adjustment data analysis and reporting.
• Maintains expert knowledge of AMA's Coding systems, including ICD-10 Diagnostic, CPT, HCPCS codes and any national updates or revisions of medical diagnostic, procedural, or medical supply coding.
• In collaboration with Plan management, participates in regulatory review and/or audit of submitted claims risk adjustment coding and recapture of HCCs.
• Oversees and develops any audits plans for readiness for CMS RADV or National Overpayment.
• Creates executive level reports and performance metrics to keep leadership up to date on risk adjustment. Review and design key KPIs on risk score trends, HCC recapture rates, and revenue accruals by PBP.
• Builds strategies for Risk optimization initiatives.
• Reviews the monthly plan payment reports and monthly membership report.

• Bachelor's degree in a related field with 7 - 10 years' experience in an HMO or MCO with direct experience working with HCC risk adjustment; or an equivalent combination of education and experience; Masters degree preferred.
• More than 2 years of experience serving as a manager.
• Experience in medical claims review/auditing, coding, or utilization management activities.
• Experience with CMS risk adjustment mechanisms, ability to read and interpret MAO-002, MAO -004, CA247 and 999 files.
• Ability to analyze and review revenue accruals for reasonability for planning purposes.
• Knowledge of medical terminology Knowledge of ICD-10 coding procedures.
• Preferred knowledge of chronic conditions and related issues in a diverse population.
• Highly skilled with Microsoft Word, Excel and Access.
• High level of critical thinking skills.
• Skilled at coaching and developing staff.
• Demonstrated ability for assessment, evaluation and interpretation of medical information.
• Ability to effectively manage projects and develop work plans.
• Ability to collaborate and educate medical providers.
• Ability to read and interpret physician documentation.