Manager, Medicare Risk Adjustment

Develops short-term and long-term strategies to meet risk adjustment accuracy goals and requirements.

• Works internally, and with BCBSA, providers, and vendors to review programs, processes, and data collection for improvement opportunities.
• Manages the production of performance dashboards to monitor and report ongoing performance against targets. Adjusts as needed to ensure goals are met.
• Ensures processes and documentation supports risk adjustment program requirements.
• Supports internal and external teams as a subject matter expert of Medicare Advantage Risk Adjustment.
• Manages necessary changes to existing systems, operations or workflows to address new / revised requirements of CMS / DHS / MQD.
• Structures work plans and project scope to deliver business impact on high priority issues.
• Addresses any identified deficiencies in current program quality and administration.
• Directs regular organization-wide training to develop staff in other key departments as risk adjustment subject matter experts in context of department work.
• Meet as needed with the Vice President and Director to review progress, report key results and program performance measures and to reestablish priorities.
• Conducts regulatory analyses and facilitates requirement development, and implementation tracking.
• Contributes to the development of business strategies for the Medicare line of business.
• Effective management of staff

Oversees and manages workflows to ensure that services and requests are handled consistently, effectively, and efficiently in order to minimize risks to members and the organization. Documents workflows and work processes.

• Manages risk adjustment team members and vendors in order to achieve program and project goals. Adjusts roles and responsibilities as needs change.
• Responsible for ensuring that Medicare Programs contract is meeting risk adjustment requirements established by CMS.
• Performs various employee management functions including but not limited to; talent management, development, performance reviews, and handles any related adjustments to salary or job description.
• Cross-Functional Integration and Communication

Acts as the leader and champion of risk adjustment interventions.

• Develops strong partnerships with key areas throughout the organization and external partners to continually improve risk adjustment accuracy performance.
• Provides education and information to the entire HMSA community regarding Medicare Advantage risk adjustment. Communicates performance results to all levels of staff including executive management as needed.
• Other Duties / Functions

Performs all other miscellaneous responsibilities and duties as assigned or directed.

LI-Hybrid

• Bachelor's degree and five years of related work experience or two and half years of experience in payer operations / responsibilities in Medicare Advantage Risk Adjustment; or an equivalent combination of education and experience.
• Two years of leadership or management / supervisory experience.
• Effective verbal and written communication skills.
• Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.