Gateway Health Plan
Job Description :
This job provides overall direction, sets goals and leads the overall risk adjustment analytics program. Functions as the business owner of risk analytics, risk adjustment data submissions (RAPS, EDPS, Medicaid state- based encounter submissions), identifies and applies best practices and processes to ensure efficiency and accuracy of risk adjustment programs. Identifies and recommends both strategic and tactical improvements to these processes, and ensures compliance to all applicable laws, guidance, and regulations. Develops and sustains a long-term optimal structure and processes around emerging encounter data submission requirements; analyzing, monitoring, and planning key risk adjustment milestones and identifying improvement opportunities. The incumbent oversees the project management and business analysis functions for the Risk Adjustment Analytics Program. Responsible for thought-leadership and project management expertise to facilitate the development of the department’s strategic plan, and to deliver key strategic initiatives and critical Program(s)/Project(s) within the constraints of scope, quality, time and budget. Directs the requirement development, testing and refinement of the underlying systems, defines strategic and tactical approaches to improve business systems to support the underlying workflow of these systems, and is a facilitator of the divisional planning process. Includes the oversight of staff that serve on Program(s)/Project(s) to deliver solutions for risk adjustment programs. Collaborates with stakeholders on project planning, risk mitigation, contingency planning and execution to ensure delivery of expected outcomes. Functions as the primary advisor of strategic direction on risk adjustment and collaborates and communicates with both clinical and operational executive management and external vendor partners
- Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Support Executive Leadership in identifying, promoting and executing analytic strategies and programs.
- Assist in facilitating the development of the department’s risk adjustment strategic plan by working with all areas of the department, along with external stakeholders, to set strategic direction. Provide project management and business analysis expertise to deliver key strategic initiatives and critical Programs/Projects.
- Establish and maintain best practice techniques for project management and business analysis functions within the Risk Adjustment department.
- Develop and oversee implementation of risk adjustment programs and processes for the collection, submission, and reconciliation of government required data in full compliance with all applicable laws, guidance, and regulations. Ensure member and product risk revenue profiles levels are accurate.
- Lead the Organization to continuously improve its risk adjustment program performance through analytics along with accuracy, timeliness and completeness of data submissions and leveraging industry leading best practices. Build and lead cross-functional teams to develop and sustain processes for analyzing and responding to ever changing CMS requirements.
- Maintain expert knowledge of principles and methods or planning, directing and maintaining compliance with risk adjustment standards. Effectively mitigate risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties. Highly collaborative and influential across the enterprise, requiring cross-functional, matrixed relationships. This includes overseeing the integration and alignment or risk adjustment, STARS/HEDIS and care management strategies, tactics and operational processes, and demonstrating ability to partner, inspire and motivate across organization structure.
- Apply knowledge of Medicare Advantage and Medicaid to partner with other revenue program management directors in identifying opportunities to improve overall program performance.
- Other duties as assigned.
- Bachelor’s Degree in Business Administration/Management, Finance, Health Administration or Related Field
- Master’s Degree in Business Administration/Management, Finance, Health Administration or Related Field
- 7 – 10 years in the Health Insurance Industry
- 7 – 10 years in Project/Program Management in large scale, cross divisional and multi-year projects
- 5 – 7 years in Management
- 3 – 5 years in Managed Care
- 7 – 10 years leading Medicare Advantage or Medicaid Risk Adjustment Programs
LICENSES AND CERTIFICATIONS
- Proven leadership experience in functional and matrix aligned organizations
- Strong communication and interpersonal skills
- Strong management and motivational skills to coach, teach, and mentor the team on core behaviors
- Excellent conflict and resolution skills to successfully navigate difficult personalities and situations
- Strong understanding of multiple software development life cycle methodologies
- Strong understanding of Portfolio Management methodology
- Outstanding organizational and written communication skills
- Excellent interpersonal and oral communication skills
- Strong leadership skills, and ability to work well at all levels within the organization
- Strong commitment to continuous process improvement and effective change execution
- Strong analytic problem solving skills and business acumen
- Ability to build strong culture of collaboration and teamwork
Language (Other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Does Not Apply
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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