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VP Risk Adjustment & Performance Improvement

POSITION SUMMARY
Transformative position that requires innovative approaches and process improvements to ensure the Health Plan capitalizes on quality and revenue opportunities associated with the Stars program, the risk adjustment process, the Health Plan’s Comprehensive Health Assessment (CHA) program, NCQA accreditation, and strategies to drive improved quality and financial improvement of the Health Plan.
PRIMARY ACCOUNTABILITIES
1. Provides leadership for development and execution of Health Plan’s performance and improvement strategy including the Stars Program, NCQA, and Risk Adjustment program.
2. Responsible for the Health Plan’s annual Quality Improvement Work Plan, the prior year’s Work Plan Evaluation, and preparation of the Quality Improvement Program Description. Ensures documents meet compliance requirements and are prepared for board approval.
3. Responsible for State and Federal regulatory activities working to promote and ensure Risk Adjustment activities are compliant with all applicable laws, regulations, rules and policies. Serves as Health Plan liaison to external regulatory bodies relating to clinical quality performance and improvement projects, including CMS, NCQA, etc.
4. Responsible for the Health Plan’s bi-annual NCQA accreditation process. Ensure compliance with standards, manages the audit process, and executive owner of the Health Plan’s NCQA overall rating.
5. Responsible for the oversight and development of programs to meet business objectives, CMS regulations and quality standards for Medicare Advantage Risk Adjustment and Commercial Risk Adjustment lines of business.
6. Manages the development of provider audit processes to meet and maintain regulatory/accreditation/operational requirements, including reporting a detailed analysis of the issue, making recommendations and following the outcome.
7. Manages the Comprehensive Health Assessment program with Integrated Delivery Network (IDN) partners to include: provider education, coding, auditing, referral process and all operational requirements.
8. Directs and manages National and CMS driven Medicare Risk Adjustment Audits and related projects, i.e. Benchmarks, Probe Audits, MA RADV and HHS RADV for QHP lines of business. Responsible for improving coding accuracy for all providers and effectively manages risks associated with RADV audits.
9. Leads the design of practice level quality transformation through targeted clinical education and approved materials related to HEDIS.
10. Serves as the leader for driving the Health Plan strategy to achieve high level performance in all quality ratings programs such as Medicare Star, Marketplace Star and NCQA ratings. This position is ultimately responsible for the Health Plans Annual Star rating which is a critical factor in the Health Plan’s financial success.
11. Leads education for providers and staff in understanding quality, HEDIS and CMS –HCC Risk Adjustment driven payment methodology and the importance of proper chart documentation of procedures and diagnosis coding.
12. Maintains an in depth understanding of all quality measurements, including HEDIS, HOS,
& CAHPS. Supports HEDIS collection process with focus on removal of barriers to chart abstraction.
13. Accountable for the member experience related to Performance Improvement activities, including oversight all outgoing member materials that will drive member engagement in their health care.
MINIMUM QUALIFICATIONS
• Education: Master’s Degree
• Work Experience: Ten years related work experience
• Knowledge/Skills/Abilities:
o Excellent verbal and written communication skills including the ability to interact professionally with all levels of the organization. Strong analytical, reporting and problem solving skills
o Subject matter expert in all areas of Risk Adjustment including Federal Medicare Program, Medicare Advantage Plans and Commercial (QHP) plans including compliance, audits, chart review, and reporting requirements
o Review and analyze data file submissions to the Centers for Medicare & Medicaid (CMS) and external vendor for accurate and complete data processing
o RADV audit (Risk Adjustment Data Validation) experience
o Strong organization skills and prioritizing ability

Time:  Full time
Salary:  Salary
Category:  Administration

Updated: 2/14/2020 2:44:06 PM