VP of Risk Adjustment is responsible for the overall management and implementation of various initiatives including, but not limited to, Risk Adjustment Programs. It is also accountable for the overall development, monitoring and oversight of Medicare adjustment initiatives and operations.

ESSENTIAL DUTIES:
Accountable for the overall integration, management, and implementation of the Medicare Risk Adjustment Program across Alpine.
Oversees and completes all aspects of Risk Adjustment projects and initiatives.
Oversees day-to-day risk adjustment related operational activities:
Coding team operations, including decision support on coding issues.
Coding processes and procedures, ensuring that the diagnosis supports the medical necessity of the procedure.
Participation in CMS user group calls and regional meetings.
Quality oversight on accurate and timely completion of data input
Data collection analysis for patterns and trends to identify opportunities to improve documentation.
Responsible for ensuring documentation is consistent with CMS regulations, company goals and policies.
Leverage predictive analytics and other insights from analytic teams to identify opportunities and develop innovative interventions to improve care management.
Continually refine quality assurance program to monitor, audit, and improve the quality of provider medical record documentation, diagnosis coding, and the coding work of staff or vendors
Identify innovative opportunities; provides guidance and suggestions for quality performance improvements in the collection and recording of clinical documentation.
Responsible for educating and keeping stakeholders current on changes in the marketplace as well as state and federal regulatory changes. ·
Manage third-party relationships that support the risk adjustment function.
Manage CMS audit/data validation
Develop collaborative partnerships with Finance, Clinical Operations, etc. to achieve objectives.
Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

EDUCATION:

Master’s Degree preferred, ideally in health care administration, business, or related field

EXPERIENCE:

Minimum:
10 years of experience in health care, managed care, health insurance or strategic consulting
6 years’ leadership / management experience
4 years’ experience in medical record review, case management, utilization management, managed care, Home Health, QA Review, HEDIS review
4 years’ experience with healthcare payment and coding methodologies (i.e., ICD-10, CPT, DRG and HCC coding).
Demonstrated ability in influencing various functional leaders in a matrix-based organization
Strong organizational and project management skills.
Excellent oral and written communication skills.
Demonstrated ability to facilitate meetings, discussions, and consensus processes.
Experience and comfort in using Word, Excel, and PowerPoint.
Ability to effectively operate independently and under tight deadlines.
Ability to work in partnership with clinicians, payers, vendors, and other key stakeholders.
Experience with quality-based and/or risk-based health insurance contracts

KNOWLEDGE, SKILLS, ABILITIES:

Excellent communication and people skills including the ability to negotiate and resolve conflicts and build teams.
Demonstrated creativity and flexibility, with the ability to operate in high-pressure situations.
Excellent organizational skills.
Demonstrated innovative approach to problem resolution.
Ability to work collaboratively across entities and disciplines, promoting teamwork.
Broad knowledge of modern health care administration practices and principles within a managed care environment.
Ability to develop and analyze options, recommend solutions, and solve complex problems and issues.
Effective organizational, planning, and project management abilities.
Experience in financial and programmatic presentations.
Ability to function independently and deal with multiple, simultaneous projects.
Ability to recognize personal strengths and weaknesses and develop goals for professional growth and achievement.
Ability to demonstrate a commitment to quality and excellence.
Ability to implement change in a positive, sensitive, and forward-thinking manner.
Developing goals and objectives while establishing priorities.
Inspires confidence, appropriate risk-taking, and achievement of lofty standards.
Initiative-taker with a willingness to try innovative ideas.
Positive, can-do attitude coupled with a sense of urgency, good judgment, and ability to act decisively at the right time.
Ability to persuade others and develop consensus.
Effective communication skills both in written and verbal presentation with a communication style that is open and fosters trust, credibility, and understanding.
Must be willing to travel for meetings.

Physician Health Partners jobs

Vice President, Risk Adjustment