Risk Adjustment Manager

Risk Adjustment Manager

General Summary: This role is key to the success of the Managed Care (MC) Department and is accountable for achieving Risk Adjustment goals and objectives. The Risk Adjustment Manager plans, directs, and coordinates the Risk Adjustment team operations including allocating and delegating work duties, tracking Risk Adjustment metrics, analyzing and resolving problems, staff training and supervision. Provides training and ongoing support to GMG Providers and the staff. In addition, the Manager supports the other Managed Care teams providing information flow and serving as a resource and mentor. The Ris Adjustment Manager analyzes department activities and collaborates closely with clinical teams, providers, and other GMG departments to achieve organizational goals, and an efficient and effective Risk Adjustment process.

Supervisory Responsibilities:  Supervises assigned staff. Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws.  Responsibilities include interviewing and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

General Requirements: All duties performed will be done accurately and in a timely manner.

1. Provides clear directions, consistent and timely feedback to Managed Care Risk Adjustment staff. Promotes teamwork in daily activities, exercises diplomacy and consistently uses effective communication skills, acting as a role model to employees.
2. Supports GMG goals by actively participating in Orientation, Training Programs, Task forces, Project Teams, and other special endeavors.
3. Ensures that Managed Care staff maintains strictest member and company confidentiality; ensures member health information is secured each day; HIPAA knowledge and focus.
4. Generates regular reporting to Providers, Pod staff, Clinical Operations Team, and MC team on Risk Adjustment Completion, Scheduling reports, High Risk patients, etc.
5. Responsible for the hiring, training, on-going supervision, discipline, and evaluation of Risk Adjustment team staff. Provides a comprehensive orientation and ongoing staff development Provides timely comprehensive staff evaluations.
6. Ensures staff members follow departmental and organizational policies and procedures, including thorough knowledge of the Risk Adjustment process and compliance with GMGs mission, vision, values, and behavioral expectations.
7. Able to work efficiently under pressure.
8. Performs other duties as assigned.

Essential Job Responsibilities:

1. Plans, directs, and coordinates all departmental Risk Adjustment activities including scheduling, staffing and oversight of team operations. Coordinates work schedules, coverage plans and assignments for Risk Adjustment Coordinators and Risk Adjustment Nurses.
2. Throughout the Risk Adjustment coordination process, monitors the status of Risk Adjustment visits and seeks to optimize patient RAF scores, Risk Adjustment visit completion rates, as well as ICD10 and HCC code capture/resolution.
3. Develops and Maintains the Risk Adjustment and High-Risk database, monitoring documentation accuracy and identifying modifications that will optimize High Risk patient management, data integrity and operations.
4. Reviews and monitors the Risk Adjustment visit documentation in Centricity to ensure system Risk A Risk Adjustment justment tools are used, and coding rules are met. Submits appeals when auditors have incorrectly discounted codes.
5. Develops training and ongoing support to GMG Providers and their staff so they are able to successfully document patient acuity and achieve accurate risk adjustment scores.
6. Facilitates meetings with clinics, physicians, and staff on a regular basis as the subject matter expert with RM Risk Adjustment data and reporting.
7. Identifies opportunities for operational improvement, and works collaboratively with the Risk Adjustment team, Provider PODS, and other GMG departments. Communicates effectively with clinic staff, internal providers, patients, and external providers regarding Risk Adjustment issues, results.
8. Serves as liaison with all contracted health plans, all Risk Adjustment/RAPS matters, attestations, logistics of audits, on site and remote auditors, appeals, etc.
9. Sets annual departmental goals and objectives and takes responsibility for their achievement. Effectively engages Managed Care/ Risk Adjustment staff in accomplishment of goals. Active participation and support of all GMG and Managed Care activities that promote patient growth and retention, improve customer service and teamwork.
10. Develops, reviews, and maintains Managed Care/ Risk Adjustment policies and procedures. Participates in the development of organizational policies and procedures.

Education and Training: Minimum high school education or equivalent Risk Adjustment required.   Associates Degree required. Prefer BS, BA, or master’s in healthcare related field.

Experience: Requires at least 5 years’ experience in Managed Care, preferably with Risk Adjusted Payment System and Utilization Management experience. Also requires previous supervisory/management experience of at least 3 years. Must be able to use basic office equipment.  Must have knowledge of ICD-10 and CPT-4 coding, medical terminology and data analytics. Must have strong verbal and written communication skills.

Other Requirements: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Work Environment: Depending upon the area assigned, may be 100% clinical setting, office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 10 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to our culture and core values.

Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position.  Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor.  Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.