Dir Risk Adjustment Analytics

Job ID: J161542
Company: Gateway Health Plan
Location: Pittsburgh,PA,US
Full/Part Time: Full time
Job Type: Day (United States of America)
AHN Facility:
Posted Date: May 22, 2020

JOB DESCRIPTION

Company :

Gateway Health Plan

Job Description :

JOB SUMMARY

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

ESSENTIAL RESPONSIBILITIES

  • 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.

EDUCATION

Required

  • Bachelor’s Degree in Business Administration/Management, Finance, Health Administration or Related Field

Substitutions

  • None

Preferred

  • Master’s Degree in Business Administration/Management, Finance, Health Administration or Related Field

EXPERIENCE

Required

  • 7 – 10 years in the Health Insurance Industry

To Include

  • 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

Preferred

  • 7 – 10 years leading Medicare Advantage or Medicaid Risk Adjustment Programs

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • 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)

None 

Travel Required

0%  – 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Does Not Apply

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required 

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

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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Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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BENEFITS

Total Rewards Program

In addition to competitive pay rates and flexible career growth, we show our employee appreciation through a comprehensive Total Rewards package, including:

  • Medical and prescription drug, dental and vision coverages for your and your eligible dependents
  • Health Saving and Flexible Spending Accounts
  • Life, AD&D and disability insurance
  • Employer-sponsored 401(k) plan
  • Paid time off, including paid holidays
  • Tuition reimbursement
  • Volunteer opportunities
  • Voluntary benefits
  • Employee discounts
Wellness Resources and Programs
Employees have access to the following wellness programs and resources:
  • Work-life resources, such as employee assistance programs and financial counseling services
  • 24/7 telephone access to health and wellness coaching to achieve personal goals
  • Onsite pharmacy services at major campuses
  • Fitness center access for all employees inclusive of showers, lockers, and group exercise classes at major Highmark campuses, Allegheny General Hospital & West Penn Hospital
  • Access to chronic condition management programs when enrolled in the employer-sponsored medical plan
  • 100% coverage for preventive exams, including flu shots
  • Incentive program that rewards employees
  • Secure bicycle parking at major campuses
  • Healthy food options at onsite cafeterias
  • Employee networks to gather in the name of health
  • Onsite seated massage and stress management classes including yoga, mindfulness and meditation

LIVING IN PITTSBURGH

Pittsburgh, PA is home to Highmark Health’s corporate headquarters, as well as the headquarters of many of our businesses and a majority of our career opportunities. When you live and work in Pittsburgh, you’ll experience a wide variety of lifestyle advantages. Take a look around and you’ll quickly see why Pittsburgh is one of America’s most liveable, most affordable, safest and happiest cities. Learn more about this exciting and inviting location:

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