Risk Adjustment Manager

Risk Adjustment Manager

Department: Quality - Risk Adjustment

Employment Type: Full Time

Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Reporting To: Nallammai Vijayakumar

Compensation: $102,000 - $115,000 / year

Manages the risk adjustment initiatives for the organization, including in-home health assessments, embedded NP, medical chart retrieval, HCC risk adjustment data & documentation integrity, and supporting vendor programs. Oversees implementation of programs designed to ensure all diagnosed codes and conditions are properly supported by appropriate documentation in patient chart. Programs include but are not limited to training and educational activities, Nurse Practitioner and AWV programs, clinical chart review programs, retrospective reviews, encounter submission, data reconciliation, and electronic data submission including supplemental data submissions.

• Oversees daily regional operations of the coding and specialists’ team, retrospective and prospective review teams and programs and ensures the appropriate strategy, tactics and data capture processes are in place.
• Collaborate closely with providers and regional network leadership teams to implement risk adjustment education, processes, and programs effectively for accurate and compliant capture of members' conditions.
• Identify and analyze implications of key changes to the regulatory & policy environment on provider organizations in the areas of risk adjustment and compliance.
• Serves as the vendor (Chart review/AWV/Cozeva etc) and provider liaison to ensure coordination of efforts, effective relationship management, cost effectiveness, delivery of work product, quality of work, delivery of required training for internal associates and timely communication on all issues.
• Manage the regional employed NP program and the vendor driven AWV program.
• Audits the chart review outcomes provided by the risk adjustment vendor and audits provider coding trends to identify potential gaps.
• Support effective business relationships with external entities, including payers and health plan partners with continuous focus on performance improvement related to population clinical quality and patient experience goals.
• Requires significant collaboration with internal stakeholders including, but not limited to, primary care section and specialty service lines, IT, business services and finance, contracting, compliance, as well as external entities and vendors will be required.
• Manage regional Provider Incentive and Member Incentive Programs.
• Recover dx codes from institutional encounters through hospitalists/encounters.
• Roll out new regional programs as applicable to improve documentation and accurate coding.
• Ensure the accuracy of risk data in and out of core systems.
• Establish EMR connectivity with Astrana Health and provider group/IPA.
• Ensure compliance with all applicable regulatory and accreditation guidelines such as CMS, NCQA, DMHC etc.
• Develop policy and procedures as required for departmental improvements.
• Complete special projects when required.

• Bachelor's Degree
• Current AAPC or AHIMA certification (CCS, CCS-P, CPC, CPC-H, CPC-P, RHIT, or RHIA)
• 5 years’ experience of risk adjustment, project management, operations, quality improvement or data analysis/reporting experience in the healthcare industry
• 5 years’ experience in managerial or supervisory capacity
• Previous experience in value-based revenue and risk adjustment improvement initiatives
• Experienced with health plan guidelines/criteria/ICE/CMS/NCQA/DMHC
• Ability to effectively present information within and outside the organization
• Advanced ability to manage and work with minimal supervision or absence of detailed instruction.
• Strong computer skills with proficiency using all Microsoft Office products, and demonstrated ability and willingness to learn new software.
• Excellent time management, project management, organizational and communication skills.

• This is a hybrid role within the United States. The home office is aligned with your department at 600 City Parkway West, 10th Floor, Orange, CA 92868.
• Wor…