Risk Adjustment Business Operations Director; Hybrid

PURPOSE

The Risk Adjustment Business Operations Director oversees the outcomes and business operations of risk adjustment for Medicare Advantage, Medicaid, ACA/BHP markets. The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key functions, overseeing enterprise risk adjustment performance while identifying areas of improvements and implementing in year programs. In addition, the Director evaluates, modifies, maintains & executes the provider facing Risk Adjustment/Risk Adjustment Data Validation (RADV) programs & actions across all the assigned populations and products.

This role collaborates and partners with Risk Adjustment Operations Team and enterprise stakeholders across to manage performance and programs to improve accuracy.

PURPOSE:

The Risk Adjustment Business Operations Director oversees the outcomes and business operations of risk adjustment for Medicare Advantage, Medicaid, ACA/BHP markets. The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key functions, overseeing enterprise risk adjustment performance while identifying areas of improvements and implementing in year programs. In addition, the Director evaluates, modifies, maintains & executes the provider facing Risk Adjustment/Risk Adjustment Data Validation (RADV) programs & actions across all the assigned populations and products.

This role collaborates and partners with Risk Adjustment Operations Team and enterprise stakeholders across to manage performance and programs to improve accuracy.

• Define and establish standards and frameworks for in year Risk Adjustments related to KPIs, OKRs, ROI, action plans, progress and risks. Establish programs for key data elements to meet industry standards and assess risks adjustments across all relevant risk domains. Develop and manage tracking tools, dashboards, and metrics for monitoring the progress of the Risk Adjustment Program across all lines of business.
  
  Drives member and provider interventions closely to ensure comprehensive quality of care that includes preventive medicine screenings and the ongoing assessment and evaluation of chronic conditions. Support the development and delivery of enterprise and market wide training and awareness materials that educate associates and leadership on best practices, pervasive operational risk adjustment issues, risk adjustment tools and processes, and lessons learned.
• Oversee the enterprise risk adjustment process, including impact analysis and actions related to risk adjustment-related regulatory changes. Drive to implement appropriate changes necessary across Care First teams and processes to impact business outcomes through development of action plans. Collaborate across the eco-system such as CMS, State, District & BCBSA to drive necessary regulatory improvements. Ensure that risk adjustment activities and decisions are aligned with strategic goals and objectives, and are executed in consideration of the impact on the organizations goals.
• Establish standards for in year programs and provide advisory support in the completion of Risk Adjustment processes, as well as govern, support, and mentor associates within the prospective & retrospective strategies to ensure accurate and complete RADV mitigation, encounter & ACA EDGE submissions. Develop and implement action plans related to accurate and complete prospective, retrospective, and regulatory data submissions affecting assigned products and plans, including detailed work plans, issue logs, and progress reports at the Plan, Provider, LOB, member level.
  
  Serve as an SME to guide Care Firsts VPs of Enterprise Quality, Stars & Risk Adjustment & Network along with Actuarial and P/L owners for each line of business, regulatory filings, and financial performance planning & reporting.
• Forge and maintain strategic partnerships across the enterprise to identify risks, improve control effectiveness, and drive cross-functional process improvements that support organizational objectives. Lead, mentor, and develop teams, vendors, and project resources by establishing performance expectations, monitoring goals and milestones, implementing corrective actions as needed, and ensuring alignment with Risk Adjustment strategy, business goals, and organizational priorities

This position manages people - 1-5 5-10

Education Level: Bachelor's Degree in Health Care Administration, Public & Population Health, Finance, Business Analytics, or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

• 8 years of progressive responsibility in healthcare.
• 3 years specifically in risk adjustment environment, within healthcare insurance within Government Programs (MA & Medicaid) & ACA.

• Masters in Business Administration, Masters in…