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Manager, Risk Adjustment

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Publicado há 27 dias

About Us:

Our mission

SCFHP's mission is to improve the well-being of our members by addressing their health and social needs in a culturally competent manner and partnering with providers and organizations in our shared commitment to the health of our community.

Our vision

Health for all – a fair and just community where everyone has access to opportunities to be healthy.

About the role:

The Manager of Risk Adjustment is responsible for the effective and efficient operation of all processes designed to ensure a successful Medicare Risk Adjustment (RA) program. The Manager will lead the development, implementation and oversight of RA staff, vendors and strategies to ensure complete and accurate risk adjusted revenue. RA strategies include but not limited to: prospective and retrospective activities, provider education, staff and vendor oversight, and data validation.

Day to Day:

  • Executes operational policies and procedures for all RA programs and processes in coordination with internal operational units of SCFHP. Processes include coding accuracy improvement initiatives, data collection and submission, internal coding program development and implementation, data validation and accuracy, assistance with provider training, Federal and State audit and compliance requirements including vendor management and audits
  • Represents the organization in dealing with vendors, delegated entities, providers, the Centers for Medicare and Medicaid Services (CMS) and the Department of Health Care Services (DHCS).
  • Reports and tracks operational and financial metrics to evaluate program performance, explaining to financial and non-financial audiences
  • Collaborates with internal departments to conduct an annual RA readiness assessment including an analysis of readiness for a CMS RA Data Validation (RADV) and provide recommendations to leadership.
  • Coordinates RADV audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and direct medical record chart reviews to validate diagnoses.
  • Drives collaboration, integration and alignment of risk adjustment programs with STARS/HEDIS and care management strategies, tactics and operational processes.
  • Monitors compliance with the Centers for Medicare and Medicaid Services (CMS) risk adjustment guidelines as well as guidelines set forth under the ICD-10-CM Official Guidelines for Coding and Reporting and any associated American Hospital Association (AHA) Coding Clinic guidance.
  • Provide oversight to claims auditor to facilitate claims payment policy and/or process changes resulting from audit findings. Provide input to the Claims department on reimbursement methodologies and process improvements.
  • Providing effective leadership to attract and retain top talent to drive business results, including recruiting, interviewing, and hiring.


About You:

  • Bachelor's Degree in Business Administration, Health Care, Economics, Finance, Policy, or related field.
  • Minimum of five years in health care with three years in risk adjustment experience working for or in support of Managed Care Organizations, preferably at a Medicare Advantage plan.
  • Minimum three years of progressively responsible experience in a supervisory role.
  • Knowledge of health care coding (CPT-4, HCPCS, ICD-9-CM, ICD-10CM and modifiers) and billing systems.
  • Understands the rationale behind the RA payment structure, concept behind current RA methodology, how current work processes impact RA, and future trends of RA.
  • Strong project management skills with the ability to manage projects from conception to a conclusion, including resource allocation, budgets, and priority
  • Ability to facilitate meetings and give presentations to management and staff.

Please review the full job description on our Career's page https://phf.tbe.taleo.net/phf04/ats/careers/requisition.jsp?org=SANTCLAR2&cws=1&rid=962'

About Us:

Our mission

SCFHP's mission is to improve the well-being of our members by addressing their health and social needs in a culturally competent manner and partnering with providers and organizations in our shared commitment to the…

Resumo dos Detalhes

  • Comprometimento de Tempo
    Carga Horária Integral
  • Educação
    Ensino Superior Requerido
  • Nível profissional
    Gerencial
Salário
USD $130.587 - USD $202.409
/ ano

Benefícios

  • Competitive wages. We keep track of the current market and local economy to offer our employees competitive pay ranges, regular increases, and longevity bonuses.
  • Comprehensive health insurance, including vision and dental coverage. Employees have their choice of medical plans through the California Public Employees' Retirement System (CalPERS).
  • Other insurance. We offer life insurance, accidental death and dismemberment insurance, and long-term disability insurance.
  • Generous paid time off—with cash-out and carry-over options. We want our employees to have time to rest, relax, and grow outside of work. Paid time off increases with longevity and starts at 18 days per year for regular employees.
  • Flexible spending accounts. This includes optional pretax accounts for healthcare, dependent care, and transit and parking.
  • Retirement benefits. Benefits are made up of four different programs: CalPERS Pension Plan, 401A Discretionary Plan, 401A Supplemental PEPRA Plan, and an optional 457 deferred compensation plan.
  • Union representation. Certain positions are represented by the Service Employees International Union.
  • Wellness perks. Health isn't just for outside the workplace. We strive to maintain a thriving work environment with standing work stations, an on-site gym, and a low-cost farmers market. We also offer free, confidential counseling 24 hours a day, 7 days a week through our employee assistance program.
  • Financial services. Employees of SCFHP get help investing wisely and planning for the future through financial planning, investment counseling, and retirement planning workshops. Employees also have the opportunity to join the County Federal Credit Union.
  • Travel and education. To help our employees expand their horizons, we offer tuition reimbursement for continued education and development. We also offer discounts on certain hotels and cell phone plans, as well as emergency travel assistance via the TravelConnect program.
  • Competitive wages. We keep track of the current market and local economy to offer our employees competitive pay ranges, regular increases, and longevity bonuses.
  • Comprehensive…

Localização

Temporariamente Remoto
O trabalho pode ser executado em ou perto de San Jose, CA
Local Associado
6201 San Ignacio Ave, San Jose, CA 95119, USA

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