Maximizes revenue strategies for CHOICE Medicare Advantage products. Coordinates multiple cross functional activities and projects related to risk adjustment across all CHOICE departments as well as interactions with external vendors. Strong understanding of healthcare operations and the ability to analyze data and processes to assist senior leadership in formulating various risk adjustment initiatives. Oversees the performance of the person(s) and vendors in charge of chart audits, home visit assessments and the performance of internal resources devoted to the Hierarchical Condition Category/Risk Adjustment Factor (HCC/RAF) efforts. Collaborates with the data science and business intelligence teams to determine potential data analytics initiatives with the focus on improving operations to improve risk score accuracy. Works under general direction.
- Serves as a liaison between the various CHOICE departments including but not limited to Finance, Service Ops, Medical Management, Business Intelligence, Provider Relations, Compliance and Quality. Maintains relationships with external vendors and provides ongoing support to manage initiatives across Risk Adjustment.
- Possesses strong working knowledge of Medicare Risk Adjustment methodology, Medicare payment policies, coding and documentation practices, and process improvement and optimization techniques.
- Manages risk adjustment vendor agreements. This includes comparing fees, financial and quality performance against competitors on an on-going basis, and reviewing risk metrics with senior leadership.
- Develops and maintains an expert level of knowledge of Medicare and risk-based reimbursement methodologies.
- Has a strong understanding of encounter and risk adjustment data and is able to identify gaps and recommend strategic initiatives for revenue maximization.
- Serves as a key contributor to develop and implement of the annual risk adjustment strategy. Works closely with the product management team and assists in annual Medicare bidding process as needed.
- Closely tracks the submission of routine federal and state data filings, report delivery to and from vendors and providers, and generally ensure that data is transmitted completely, correctly, and on time.
- Presents HCC/RAF performance results and findings to IPA’s and individual physicians, including the overall HCC/RAF score, improvement strategies and tactics.
- Identifies and prioritizes risk adjustment opportunities and identifies resources as needed.
- Develops and tracks various initiatives for risk score optimization. Assists reporting and analytics team in building operational dashboards that can be used to monitor progress across various initiatives.
- Keeps up to date on industry trends and writes reports on evolving payment policies. Monitors CMS regulations related to risk score submissions and reimbursement.
- Reviews any HPMS memos related to payment policy changes and assess the impact of the changes on operations, systems and data reporting. Attends industry risk adjustment training and assimilates learning into processes.
- Collaborates with Quality Improvement (QI) department on Stars and/or or other initiatives.
- Develops and audits Risk Assessment Data Validation (RADV) readiness plan and monitoring program.
- Collaborates with internal and external experts to develop metric-supported strategies that improve revenue and decrease risk exposure.
- Develops plans to ensure successful completion of internal and external risk adjustment data validations, including contingency planning.
- Participates in special projects and other duties as assigned.
Education:Bachelor’s Degree in Business Administration, Finance, Health Care Administration, or other related field required. Master’s degree in Business, Health Administration, Health Policy or related discipline preferred.
Experience: Minimum of five years experience working with health care plans and Medicare and Medicaid programs. Working knowledge of CMS and/or Medicaid risk adjustment methodologies required. Operational knowledge of provider relations, claims, and medical management required. Prior experience with Medicare risk adjustment, project management and leading cross-functional complex time sensitive projects required. Prior experience with Medicare Risk adjustment is required. Strong organizational, analytical, financial, communication and presentation skills required. Proficiency in strategic thinking, problem solving and advanced excel skills required.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.