Manager, Risk Adjustment Operations, remote

Manager, Risk Adjustment Operations, remote

(Job Number: 3213725)

For over 30 years, AllWays Health Partners has delivered value to our members and worked to improve access to care and coverage. As a member of Mass General Brigham, AllWays is a health plan at the forefront of innovation, advancing a highly integrated model of value-based care with one of the world’s leading health care systems. Together, we are transforming the customer experience, keeping our members and patients at the center of everything we do. Bring your unique talents and join us as we strive to create a world where all people live healthier lives.

This role is a key operational leader on the Risk Adjustment team. Under the direction of the Vice President, the Manager leads a team of analysts(data and clinical) and coding staff for risk adjustment related projects from conception to implementation to ongoing operations. The Manager will provide thought leadership, project management, vendor management and complex analytic work to ensure the success of the assigned project.

The Manager will direct all operations related to risk adjustment across 3 lines of business(ACA, Medicaid, and Medicare Advantage). He/she will help the team build our CMS data submission engine for Medicare Advantage and be responsible for the operational success of all our risk adjustment related data submissions. Operational success means complete and accurate acceptance of our risk adjustment data delivered to CMS. We achieve operational success by standing up robust metrics, policies, monitoring, and workflows to maintain an accurate submissions and quickly resolve CMS submission errors.

To this end, this leader will help design KPIs that allow the submission team to monitor the health of our data submission pipeline and to stand up scalable workflows to address submission error queues. It will also be critical for the manager to develop a deep understanding of the CMS/Medicaid data submission systems and track and resolve returned data submission errors against established operational turnaround times.

The Manager will lead a coding staff for medical record review to ensure the acuity of our member is accurately captured in submissions. Furthermore, he/she will lead feedback and education with our provider community where appropriate.

The Manager will lead retrospective and prospective risk adjustment programs. They will evaluate vendors for In Home Assessments, Medical Record Review, and Coding. They will stand up a new operational process for In Home Assessments. This requires working directly will Clinical and Quality to prioritize members that need this type of encounter.

This role requires interacting and influencing internal and external stakeholders to ensure project success. The Manager will follow and document all CMS and MassHealth risk related activites and ensure the company is positioned to meet any new requirements; as well as, develop ideas that enhances our company’s competitive position for risk adjustment.

ESSENTIAL FUNCTIONS

• Lead all internal and external risk adjusted operational projects
• Leads team to monitor CMS calls and presentations to ensure compliance and identify new ideas and strategies for improving risk adjustment
• Manages all vendor relationships and helps negotiate any new or existing contracts
• Develop and present complex analytics that communicate ongoing financial performance from internally custom built and externally vendor built sources.
• Lead all CMS audits
• Manage certified coding staff that conducts medical record review
• Develops strategies for provider training, education and medical management
• Evaluates data quality of internal and external datasets

• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect. • Hold self and others accountable to meet commitments.

• Build strong customer relationships and deliver solutions that meet customer expectations; establish and maintain effective customer relationships – both internal as well as external.
• Inform, engage, inspire, motivate, and actively listen to employees.
• Make decisions that put the needs of the people we serve—our members, providers, brokers, and employers—front and center.
• Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.
• Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.
• Hire, participate in, and/or recommend development measures and disciplinary actions up to and including termination; evaluate performance and supervise the work of all direct and indirect reports following established organizational policies, procedures, and practices.
• Set clear goals and objectives, use metrics to measure performance, and hold employees accountable. Provide coaching to improve performance and holds regular development meetings.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Hold self and others accountable to meet commitments.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles or setbacks.
• Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.
• Other duties as assigned with or without accommodation.

KNOWLEDGE AND EDUCATION

• Medical coding certification or equivalent experience

EXPERIENCE

• Demonstrate AllWays Health Partners’ core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it’s needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see “what is” and envision “what could be.”
• Ability to develop, introduce, defend, and gain support for a new ideas and approachess.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience; strong executive presence, presentation and communication skills. Strong verbal, active listening, and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the “big picture.”
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.