Director Risk Adjustment and Quality Analytics - Actuarial

Director Risk Adjustment and Quality Analytics - Actuarial

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At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing.

If you are ready to make a difference, join us.

We are looking for a Director of Risk Adjustment and Quality Analytics to lead a team that delivers insights and results in support of the Risk Adjustment and Quality programs. This position plays a leadership role in enabling improved accuracy in understanding the illness burden of our membership to better manage their risk, care, and health.

• Performs risk score computation and forecasting for Medicare, ACA, and Medicaid.
• Oversees diagnostic coding gap identification (suspecting), confidence modeling, and benchmarking.
• Responsible for operational metric tracking and performance improvement opportunity identification.
• Involved with the targeting and evaluation of in-home assessment, chart review, and point of care programs.
• Calculates the financial impact of various improvement opportunities and provides guidance for pricing and budget.
• Develops and monitors risk score trends to support bid development and financial forecasting.
• Tracks and evaluates risk adjustment initiatives performance across Medicare, ACA, and Medicaid throughout the year.
• Identifies and escalates potential data leakage issues for operational teams to address.
• Drives the design, development, and maintenance of dashboards to monitor risk adjustment initiatives and outcomes.
• Collaborates with provider engagement teams to track and report provider performance metrics.
• Provides audit support for RADV, OIG, and other regulatory or internal audits.
• Provides strong leadership to the Quality and Risk Adjustment Analytics team, including building a successful team, developing strategic partnerships, and influencing across Blue Cross highly matrixed organizational structure to represent enterprise risk adjustment and quality interests.
• Stays abreast of changes in the rapidly evolving health care marketplace and understands how trends, competitors, external context, and internal dynamics shape opportunities and challenges for the business.
• Effectively communicates complex concepts, strategies, initiatives, analytics, and results to a variety of stakeholders, including senior staff and executive leadership.
• Understands the strategy and future direction of Blue Cross, as well as challenges and opportunities that are inherent to that strategy and direction.
• Ensure that the priorities of the team reflect the company’s strategic direction, and ensure the teams knowledge, skills, and ability are adequate to meet current and evolving needs of the Risk Adjustment and Quality programs.
• Directs the team, including interviewing and hiring employees following required EEO and Afffnitive Action guidelines and ensuring employees receive the proper training.
• Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.

• Accepting this position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.
• 7+ years of related professional experience, with 3+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• ASA or equivalent experience.
• Demonstrated ability to evaluate quantitative data from multiple sources using statistical modeling, analytical methods, and critical thinking skills.
• Proficient with methods and tools to…