Staff VP Prospective Risk Adjustment
Miles, TX ·
Position Responsibilities
Instill governance to ensure complete and accurate diagnosis codes are identified and submitted to CMS for all members for risk adjusted payment.
Ensure timely, accurate, and complete submission of risk adjustment data to CMS and reconciliation of plan payments.
Oversee internal and vendor processes, controls, and reporting, ensuring effective processes are in place throughout the organization.
Develop, execute, and continually refine a quality assurance program to monitor, audit, and improve the quality of provider medical record documentation, diagnosis coding, and the coding work of internal staff and contracted vendors.
In collaboration with regional and local Medicare health plan leaders, develop and execute strategies, prospective programs, and plans to engage providers in proper assessment, coding, and documentation of all members' conditions.
Implement governance to improve quality, accuracy, and identification of member health conditions.
Leverage predictive analytics and other insights from Data Science and Analytics teams to identify opportunities and develop innovative interventions to improve care management.
Stay informed about CMS, industry trends, and best practices, and utilize this knowledge to refine and advance risk adjustment programs.
Position Requirements
At least 10 years Medicare or relevant healthcare work experience, including 8 or more years with risk adjustment and proven leadership experience in healthcare overseeing quality, risk adjustment, or compliance. BS in a Healthcare Economics, Business Administration or an equivalent combination of education and work-related experience.
Preferred Skills, Capabilities, And Experiences
Prior Medicare Risk Adjustment with a focus in Prospective Risk Adjustment strongly preferred.
Experience with healthcare economics and/or risk adjustment; CPC or CCS-P certification, a plus.
Process improvement knowledge and experience.
Comprehensive knowledge of payer environment and healthcare systems.
Strong financial management, organizational, negotiation, analytic, and management skills.
Demonstrated track record of driving large-scale business change, particularly in a matrix environment.
Masters preferred.
TO APPLY - Please forward resume to Paul Martin at pmartin@pailingroup.com
pailingroup.com
