Risk Adjustment Manager

The Risk Adjustment Manager is responsible for the development, execution and management of the risk adjustment programs for the Medicare Advantage and Medicaid product lines. This function is highly visible, matrixed to multiple departments, including IS, Compliance, Finance, and Network and Clinical Services, and is responsible for ensuring a high degree of quality, coordination, and collaboration across the entire risk adjustment process.

• Manage the company's risk adjustment activities and monitors performance against goals.
• Monitor accuracy and timeliness of Electronic Data Processing Systems (EDPS) submissions to ensure compliance with Centers for Medicaid and Medicare Services (CMS) regulations.
• Monitor the accuracy and timeliness of OHP 837 submissions to ensure compliance with OHA.
• Manage and evaluate the encounter data submission program.
• Coordinate the encounter data team's communication with internal and external customers as it relates to encounter data and responses to changes in the business or regulatory environment.
• Manage all RADV audits.
• Oversee and coordinate vendor selection, support, and monitoring for retrospective and prospective reviews.
• Identify and prioritize risk adjustment opportunities; identify resources as needed.
• Develop internal risk score reporting and analytics in coordination with IS team.
• Monitor CMS and OHA regulations related to risk score submissions and reimbursement.
• Attend industry risk adjustment training and assimilate learning into processes.
• Participate in risk adjustment workgroups and other related policy advocacy.
• Collaborate with Finance staff to assist with risk score forecasts and monitoring.
• Collaborate with Network and Clinical Services (NCS) department on coding improvement and risk score accuracy and completeness initiatives.
• Collaborate with Medicare and Population Health departments on Stars and/or member outreach initiatives.
• Support the annual OHA risk adjustment development process.
• Support the Health Share risk adjustment process and policy development efforts.
• Develop and/or recommend risk adjustment policies and procedures; guide process improvement and implantation.
• Complete other work and special projects as assigned.

Employee Supervision

• Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
• Train, supervise, motivate, and coach employees; provide support toward employee development.
• Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
• Ensure team adheres to department and organizational standards, policies, and procedures.
• Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
• Perform supervisory tasks in collaboration with Human Resources as needed.

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 5 years' related experience in Medicaid and/or Medicare analysis, systems, or finance, including minimum 1 year in risk adjustment and reimbursements

Preferred

• Bachelor's degree in Statistics, Mathematics, Business, Technology, or related field
• Master's degree in related field
• Extensive experience in healthcare analytics
• Minimum 2 years' experience in a supervisory position or minimum 1 year experience in a supervisory position and completion of CareOregon's Aspiring Leader Program

Knowledge

• Understanding of risk adjustment theory and CMS model
• Understanding of the CDPS Rx model
• Understanding of Medicare Advantage and OHP risk adjustment regulations and requirements
• Understanding of RAPS and 837 formats and file protocols
• Understanding of SAS macros and statistical databases
• Knowledge of medical claim coding and Medicare Advantage payment methodology

Skills and Abilities

• Ability to influence others without direct authority
• Ability to effectively interact with others at all levels in the organization
• Ability to develop and maintain strong cross-functional relationships
• Excellent analytical and problem-solving skills
• Strong written and verbal communication skills
• Leadership skills, including the ability to manage staff
• Ability to think strategically and understand detail
• Ability to work with limited supervision
• Ability to manage multiple and competing tasks and priorities
• Ability to manage cross-functional projects and initiatives
• Ability to work in a culturally, and professionally, diverse work environment

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see for at least 6 hours/day
• Ability to read, hear and speak clearly for at least 3-6 hours/day
• Ability to perform repetitive finger and wrist movement for at least 1-3 hours/day

Working Conditions

Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.

#Li-Hybrid

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Visa sponsorship is not available at this time.