Risk Adjustment Provider Programs Specialist

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Collaborates with internal departments on risk adjustment coding strategies, HEDIS performance, provider performance, and other corporate quality initiatives. Develops and executes programs and processes that support the initiatives. Leverages analytics to improve the health and experience of members while lowering costs of care. Proposes and manages strategic projects for risk revenue and provider performance optimization.

This position has the option to work remotely; Ohio residents preferred. Seeking applicants with project management and claims adjudication system experience.

Responsibilities

• Develops, coordinates and monitors outreach / intervention activities with providers to improve member outcomes, coding accuracy and quality results.
• Develops education and incentive programs that are supported by data driven analytics and results. Collaborates closely with Provider Contracting teams to ensure appropriate delivery approach and assist in the review of provider agreements.
• Acts as project manager over large internal risk adjustment projects (e.g., Optum In Office Assessment program for both MA and ACA, Diagnosis Gap Advisor for concurrent communication with providers regarding diagnosis documentation and claims submission).
• Manages vendor agreements to ensure optimal pricing and performance guarantees are included and enforced. Reviews and reconciles vendor invoices.
• Prepares and presents reports and executive summaries to a variety of audiences.
• Performs other duties as assigned.

Qualifications

Education & Experience

Professional Certification(s)

Technical Skills & Certifications

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes :

A Great Place to Work :

Excellent Benefits and Compensation :

An Investment in You :

About Medical Mutual :

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

Salary : $5,250