Job Description

JOB SUMMARY:

The Director of Risk Adjustment is responsible for the strategic design, implementation, and oversight of CCOK’s risk adjustment program for both ACA and Medicare Advantage businesses. This individual will coordinate with various areas including IT, Healthcare Economics, Finance, and the Clinical Auditing team in order to maximize the efficiency and effectiveness of Risk Adjustment strategy, analytics, and data reporting to CMS, as well as supporting processes regarding provider education and member engagement to identify opportunities for improved accuracy in coding.

KEY RESPONISBILITIES:

• Develop and execute enterprise-wide risk adjustment strategy to align with regulatory requirements and financial objectives
• Oversee all aspects of risk adjustment data analytics, including CMS reporting, clinical documentation improvement strategy, and vendor management
• Lead cross functional teams including coding, analytics, compliance, medical economics and operations to ensure seamless integration of risk adjustment initiatives
• Monitor and ensure compliance with CMS, Oklahoma regulations, and audit requirements
• Lead end-to-end timely and accurate submission of risk adjustment data to CMS including overseeing the reconciliation of CMS reports to validate submission accuracy
• Translate risk adjustment performance into actionable insights to support medical management and quality initiatives
• Drive innovation and efficiency in risk capture methodologies
• Partner with finance, actuarial, operations teams to forecast, track performance and manage risk score impacts for all contracted products
• Collaborate with Clinical Operations on provider education needs to ensure documentation and coding accuracy
• Evaluate and manage relationships with third party vendors providing risk adjustment services
• Serve as internal subject matter expert on all aspects of risk adjustment policy changes and risk scoring methodologies
• Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities
• Promote a culture of accountability, innovation and compliance.
• Performs other job-related duties as assigned.

QUALIFICATIONS:

• Expert level knowledge of Medicare Advantage and ACA Risk Adjustment reporting lifecycle and submission systems
• Possesses an insatiable need for process improvement and operational effectiveness
• Excellent communication, executive presence and relationship building skills
• Strategic thinker with excellent analytical, critical thinking, problem-solving, interpersonal, and relationship building skills.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Bachelor’s degree in healthcare administration, data science, accounting, finance, or related field; Master’s degree MBA, MHA, MPH preferred
• 10+ years of experience in risk adjustment, Medicare Advantage or related healthcare operations
• 6 plus years of management experience.

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