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Director Risk Adjustmen

This position is responsible for risk adjustment, which includes Hierarchical Condition Coding (HCC) or other risk adjusted revenue programs, to ensure complete and accurate revenue for Medicare Advantage, Individual and Small Group, and Centennial Care products. This would include but not be limited to dual eligible Medicaid/Centennial Care enrollees and Health Insurance Exchange (commercial) enrollees. Directs the activities of staff accountable for complete and accurate risk adjusted revenue through the submission and analysis of medical and pharmacy claims, prospective and retrospective review of data and related functional activities to support business unit and enterprise goals. Participates in the planning, development and standardization of reimbursement processes throughout the enterprise to assure the accurate capture of diagnoses codes, collaborates with IT, HSD and CMS/HHS to ensure that data is effectively transmitted to appropriate regulatory agencies and accepted with minimal errors
 
Responsibilities:
Responsible for assisting in the development of enterprise-wide plans and strategies for risk adjustment across all product lines as well as leading the execution of those plans. These responsibilities include but are not limited to: providing input to enterprise leadership teams regarding current structures and effectiveness of risk adjustment processes, assessing enterprise processes from beginning to end, recommending changes to processes to enterprise leadership, identifying and implementing immediate tactical changes, informing health plan and delivery system leadership regarding accomplishments and risks of achievement of enterprise objectives, executing enterprise plans and strategies through coordination with delivery system initiatives and processes, partnering with third parties and vendors and overseeing their activities, and implementing processes for contracted physicians to better manage activities impacting risk adjustments.


Responsible for ensuring complete and accurate risk adjustment to revenue for commercial and government products (Medicare Advantage and Centennial Care), including the development/implementation of policies and procedures to define and support the programs, as well as tools and technologies for on-going analytics of complete and accurate risk adjustment, and overseeing and managing all processes related to data supporting risk adjusted payments including but not limited to reconciliation of submission of data to third parties including CMS and vendors, analysis of risk adjustment payments and scores, and implementation and operation of technologies for risk adjustment. Includes the payment reconciliation process under the Health Insurance Exchange, dual eligible management, Medicare Part C & D HCC/Risk Score Coding and Accuracy, Medicare Part D PDE management and reconciliation



Chairs and provides leadership to enterprise work team comprised of representatives from PDS, PMG, PHP, PCSC, Finance, Compliance, IT and the SIU. Responsible for ensuring work is properly coordinated and all major activities and developments are communicated. Examples of activities include preparing agendas, leading meetings, and tracking progress of actions and initiatives.

Responsible for implementing and operating a technology solution to enable the tracking, monitoring, analysis and reporting of diagnosis codes that drive risk adjusted payments. Responsibilities include reconciling the data within the system to ensure completeness and accuracy, analyzing data to enable decision-making, and developing reports for management, executives, clinical leads, providers and others to support their achievement of work goals and processes. Required to work directly with contracted and delivery system providers and practices to provide appropriate tools, resources and reports.


Manages all data submission requirements for Health Insurance Exchange (commercial) and government programs, including Medicare HCC from claims capture, RAPS submissions, RAPS logic validation, RAPS reconciliation, and oversees and ensures a compliant transition to the CMS EDPS processing. Responsible for educating and keeping management current on changes in the marketplace as well as state and federal regulatory changes related to risk adjustment, reinsurance and revenue management.


In conjunction with the PHP Medicare Compliance Officer and SIU Director, oversees both internal and external audits associated with risk adjustment/reimbursement including RADV from CMS.

Negotiates and manages vendor agreements and relationships. Responsible for negotiating, contracting, and managing vendors. May include home assessment vendors, data submission vendors, special clinic vendors, coding and data analyst vendors, software companies or other subject matter experts/consultants.

Responsible for managing Presbyterian Health Plan's clinical space for the conduct of annual wellness assessment visits for Medicare Advantage members. This includes overseeing the selection of space, the leasing arrangement, and overseeing the conduct of the clinic by contracted parties.

Employs project management techniques to ensure that projects are completed on time, on budget, and with high quality results.

A Bachelor's Degree in Business or related field is required.

Presbyterian Healthcare Services is an integrated system of 8 hospitals, 36 clinics, a physician medical group and a health plan. As New Mexico's only private, not-for-profit healthcare system we exist to improve the health of the patients, members and communities we serve. Presbyterian is in an exciting period of innovation, and we are actively strengthening our integrated system to create high quality, efficient and affordable care for the New Mexicans we serve.

We are proud of our 106-year legacy of providing healthcare that began before New Mexico was even a state, and we know how important it is to ensure that we're here for New Mexicans today and in the future.
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, age, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law. PHS is committed to ensuring a drug-free workplace.

If you are interested in this position, please apply online at http://tinyurl.com/hzz6o22

Questions? Contact Nancy Whitson at nwhitson@phs.org or 505-923-7779.

Time:  Full time
Salary:  Salary
Category:  Compliance

Updated: 2/21/2017 12:35:16 PM