Manager, Risk Adjustment/ Job Req 772071299

PRINCIPLE RESPONSIBILITIES:

Under the general direction of the Director, Stars Strategy & Program Management, the Manager, Risk Adjustment is responsible for the planning, implementation, strategic oversight, and evaluation of a Risk Adjustment program for Alameda Alliance for Health's (the Alliance) Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) product. This individual will lead the development and implementation of programs and initiatives to enhance coding accuracy, including provider education and tools, and retrospective and prospective member and provider initiatives. The incumbent will also lead cross-functional initiatives to identify Risk Adjustment opportunities and drive overall organizational performance. The manager will establish a comprehensive plan to support the Risk Adjustment program for the Medicare Advantage line of business to ensure accurate and consistent reporting to government agencies and to reflect the member's accurate disease burden.

The Manager, Risk Adjustment is expected to remain current with market/industry trends and the competitive product landscape to ensure the Risk Adjustment program is implemented in a budget conscience, quality, and timely manner. The position will work closely with various departments to identify training needs and may conduct training sessions that align with business objectives.

Principle responsibilities include:

• Overseeing and acting as a subject matter expert (SME) in the development and implementation of the Risk Adjustment program for the Alliance and the Medicare Advantage D-SNP product that is consistent with the vision and mission of the Alliance.
• Designing and implementing Risk Adjustment strategies and initiatives aligned with regulatory requirements and organizational goals.
• Developing and monitoring Risk Adjustment programs, ensuring they address both retrospective and prospective risk capture while identifying areas of improvement with coding accuracy, provider engagement, and member outreach.
• Collaborating with internal and external SMEs to integrate Risk Adjustment initiatives with Star strategy objectives.
• Analyzing Risk Adjustment data, monitoring trends, and identifying gaps in coding accuracy and risk capture.
• Overseeing the day-to-day management of Risk Adjustment programs, including planning, timelines, resource allocation, and risk assessment.

• Supporting Go-Live activities to include system testing and configuration when necessary, demonstrating trained processes.
• May facilitate training sessions to increase employee and provider knowledge and competence, using visual aids such as videos, slides, graphs, charts, presentations, etc.
• Developing and maintaining an expert level of knowledge of Medicare and risk-based reimbursement methodologies. Keeps up to date on industry trends and monitors Centers for Medicare and Medicaid Services (CMS) regulations related to risk score submissions and reimbursement.
• Working cross-collaboratively with diverse staff in teams, working groups, members, providers, elected officials, community partners, and vendors while maintaining and upholding a professional demeanor and representing the Alliance at interviews, special events, official functions, meetings, and when conducting research.
• Assisting in creating policies, standard operating procedures (SOPs), productivity standards, roadmaps, reporting, and Key Performance Indicators (KPIs) in a timely manner.

ESSENTIAL FUNCTIONS OF THE JOB:

• Assumes responsibility and exercises good judgement in making decisions within the scope of authority of the position.
• Be proficient in understanding the Medicare Advantage Risk Adjustment program, ICD-10 coding, HCC coding, and CMS submission requirements.
• Demonstrates strong organizational, time management, and project management skills and multi-tasking abilities.
• Proven track record of developing and implementing successful Risk Adjustment processes and regulations.
• Provides support to the Project Management Office (PMO) and various enterprise-wide activities based on availability.
• Organizes and facilitates Risk Adjustment project-related meetings, as necessary.
• Works effectively independently as well as part of a team and supports team decisions.
• Adapts to changes in requirements/priorities for daily and specialized tasks.
• Produces accurate and precise work, detects discrepancies, and resolves discrepancies all while meeting deadlines.
• Demonstrates analytical skills and problem-solving skills as well as formulates and communicates recommendations for improvements as needed.

PHYSICAL REQUIREMENTS:

• Constant and close visual work at a desk or a computer.
• Constant sitting and working at a desk.
• Constant data entry using a keyboard and/or mouse.
• Frequent use of a telephone headset.
• Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Directly Supervised: 0-5

Number of Employees Indirectly Supervised: 0-5

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• A Bachelor's degree in business administration, economics, finance, accounting, public health, related field, or equivalent work experience

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum of five (5) years of experience in Risk Adjustment Program Management.
• Minimum of three (3) years of experience in the managed care industry with Medicare Advantage related experience preferred.
• Minimum of three (3) years supervisory experience.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Strong understanding of Risk Adjustment software, analytics tools, and submission to CMS.
• Audit experience preferred.
• Experience in project management, program management, or product development preferred.
• Strong understanding of HEDIS measures, RADV program, CMS Star Rating methodology, and regulatory requirements.
• Excellent written, verbal, and interpersonal communication skills, and ability to successfully interact with people at all levels.
• Ability to facilitate meetings, manage complex initiatives, and make presentations before groups consisting of management and staff.
• Exhibits good planning and implementation skills to ensure work is completed on time and to expected quality levels.
• Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, while maintaining effective, high-performance teams.
• Strong organizational skills with the ability to effectively prioritize multiple tasks and meet deadlines.
• Ability to lead effectively in a matrixed environment.
• Ability to communicate effectively orally and in writing.
• Basic knowledge of the business, economic, demographic, and political trends and developments affecting healthcare in general.
• Intermediate skills in Microsoft Office Suite including Outlook, Word, Excel, Visio, and PowerPoint.
• Ability to manage confidential information with appropriate discretion.
• 5% to 10% occasional travel required.
• Valid CA driver's license, proof of insurance and good driving record.

SALARY RANGE: $142,043.20 - $213,075.20 Annually

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.