Director of Quality and Risk Adjustment

Job Description

Job Description

Role Insights

The Director for Quality and Risk Adjustment is responsible for leading enterprise development of the Medicare Star Ratings and Enterprise Risk Adjustment strategies that ensure our risk adjusted and Star members are getting the right clinical and pharmacy care at the right time.

This leader drives cross-divisional execution of a multi-year strategy to achieve and maintain a Star Rating of 4 and ensure risk score accuracy and completeness in all enterprise risk adjustment activities. Development of strategy includes integrating the Star and Risk Adjustment approach to provider engagement, payment and risk sharing models, collaborative care models, data / analytics support, member engagement, health improvement and management programs and collaboration with vendor partners to achieve identified goals. Operational integration and coordination with impacted divisions within AMM to ensure support and coordination with the programs and functions including medical management, claims payment, consumer experience, product development, network management, data and analytics, grievance and appeal management, and client service to drive successful integration with the Risk Adjustment strategy. The Director will work in close collaboration with executive leadership of AMM representing Medical Management, Finance, Network Management, Operations, and other divisions. The role may involve interaction with leadership of integrated delivery systems, hospitals, clinics, and other health care provider organizations.

Primary Responsibilities

• Lead enterprise efforts to maximize the Medicare CMS Star Rating and other quality programs supporting commercial, ACA, and Medicaid lines of business.
• Ensure complete, compliant, and accurate risk scores in all risk-adjusted market segments. Develop a multi-year strategy in collaboration with organizational stakeholders including Health Care Management, Client Services, Network Operations, and other business units as needed to drive process change across the organization to improve performance.
• Lead the strategic direction of quality assurance, coding, submissions, and audit services for risk adjustment revenue optimization.
• Develop roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Collaborate with analytics team to measure the effectiveness of initiatives and process improvements.
• Track and report on initiative progress at all appropriate levels of the organization; creating or joining the necessary forums to do so.
• Coordinate with existing vendors, and / or identify and implement new vendors, in order to drive desired outcomes in risk-adjustment activities.
• Coordinate activities of Star improvement and risk adjustment accuracy and completeness such that maximum benefit is derived with minimized provider and member abrasion.
• Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing clinical, operational, and member experience quality.
• Create and lead cross-departmental initiatives to change processes such that members experience improved satisfaction with the health plan and are less inclined to dis-enroll.
• Oversee clinical Star-related clinical operations and ensure clinical initiatives for regulatory compliance and organizational alignment.
• Directs the team, including interviewing and hiring employees ensuring employees receive the proper training. Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.

Required Skills and Abilities