Risk Adjustment Analytic Manager

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* Join Pacific Source and help our members access quality, affordable care!
*** Pacific Source is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.
** Pacific Source values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Risk Adjustment Analytic Manager reports to the Director of Risk Assessment and will oversee technical aspects of Risk Adjustment operations including data staging and submission oversight, reporting and analytics, retrospective and prospective program support, vendor oversight, and RADV mitigation strategies. The Risk Adjustment Manager will lead a team of Risk Adjustment Analysts to accomplish these tasks and execute on strategy laid out by the Director and Senior Leadership.

The Manager will collaborate with internal teams such as Quality, Population Health, Actuarial, Analytics, IT, Finance, Provider Network, and others. The Manager will interact with external vendor partners to manage data flow, report sharing, and address general oversight concerns. In addition, the Manager will interact with regulatory entities such as CMS to stay updated on changes that would affect operations within the company as well as ensure fulfillment of deadline requirements.

Responsibilities include the above activities across the Medicare Advantage, Commercial ACA, and Medicaid member populations. The Manager will ensure compliance to all applicable laws, guidance, and regulations.
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* Essential Responsibilities:

*** Execute the operational aspects of the strategic direction and plan for risk adjustment including performance metrics, time frames and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives
* Develop analytic processes to help ensure accuracy and comprehensiveness of HCC reporting to CMS and assist in Risk Adjustment programs to ensure that risk exposures and opportunities are identified timely and appropriately, with a goal to optimize the program.
* Support of the Medicare Advantage Encounter Data Processing System, Risk Adjustment and Payment System (as applicable), Commercial Risk Adjustment EDGE Server, and Medicaid Encounter System from a Risk Adjustment perspective and ensure optimal submission.
* Monitor and analyze risk score trends. Work with IT and Actuarial staff to reconcile data with financials, forecast risk adjustment factors, and model impacts of potential payment changes.
* Assist with Risk Adjustment Data Validation (RADV) audits by government agencies or outside audit vendors, assisting internal stakeholders and supporting medical record reviews to validate diagnoses.
* Develop analytics and tools to mitigate risk associated with inaccurate coding and risk scores which could result in lost revenue, potential CMS sanctions or penalties, and disadvantages relative to competitors.
* Develop, maintain, and report out on actionable metrics related to risk adjustment and incorporate quality/health outcome metrics where applicable.
* Provide support as needed for projecting annual receivable amounts, preparing projections related to pricing efforts, and predicting cost utilization as it relates to risk adjustment.
* Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment data submission.
* Develop and maintain data sets leveraging internal data, response data from regulatory entities (EDGE files, MMR, MOR, RAPS…