Director of Risk Adjustment

The Director, Risk Adjustment will lead the risk adjustment program at Boston Medical Center Health System. In this role, the Director will be responsible for developing a multi-product risk adjustment strategy aimed at ensuring accurate risk coding for all BMCHP members. Joining BMCHS means joining a health system with a diverse landscape of risk adjustment activities, covering multiple different product types and spanning both the payor and provider space. BMCHP products include: Medicaid Managed care programs in both Massachusetts and New Hampshire, a commercial ACA plan, a duals plan, and a Medicaid ACO program. The Director will be responsible for building out core health plan-based risk adjustment operations, as well as developing innovative provider-based programs, and other product-specific risk adjustment strategies. Success will require competence in risk adjustment strategy, an ability to build and scale risk adjustment programs, and an ability to partner effectively with provider groups to design and implement point care risk adjustment interventions.

Key Functions/Responsibilities:
– Overall Risk Adjustment Strategy: Responsible for engaging stakeholders across the Health System (Providers, IT, Finance, Revenue cycle, etc) to define a system strategy for risk adjustment, including strategies for provider engagement, IT system capabilities, revenue cycle operations, etc
– Risk Adjustment Analytics: Partner with Clinical and Financial Analytics teams to define opportunities and areas of focus to optimize risk adjustment performance across all products
– Overall Risk Adjustment performance management: Develops and maintains risk adjustment performance management and reporting dashboard, in partnership with Clinical and Financial Analytics leaders
– Government and Regulatory tracking: In-house expert on risk adjustment models; maintains current view of risk adjustment regulatory changes and product-specific risk model changes; ensures appropriate BMCHP operational responses to regulatory and risk adjustment program changes
– Operational Oversight: Direct supervisory responsibility for Boston Medical Center Health System Coding Validation team and Risk Adjustment program management team
– Contract Management: Oversee overall vendor strategy for coding; manage various Health System contracts for coding services; ensure vendor accountability for performance
– Provider site engagement and partnerships: Partner with provider account teams to communicate risk adjustment strategies and initiatives to provider groups; partner with provider groups to implement risk adjustment initiatives
– Internal stakeholder management: Ensures open communication and collaboration across all relevant internal departments/positions that intersect with risk adjustment team (Quality, Pricing, Provider Relations, Product teams, etc)
– Specific tasks may include design and implementation of the following:
– Retrospective coding program
– Provider education campaigns
– Provider incentive programs
– Selected audit and compliance programs
– EMR optimization / other IT strategies
– Other duties as assigned

Qualifications:

Education:
– Bachelor’s degree in Business or Healthcare Administration or related field required
– Advanced degree preferred

Experience Required:
– Ten (10) years of progressively responsible experience in health insurance industry with specific experience in risk adjustment

Preferred/Desirable:
– Technical Skills and Knowledge:
– Advanced statistical analysis and Microsoft office (including Access) skills
– Comprehensive knowledge of health plan activities with emphasis on ACA and Medicare Advantage Risk Adjustment models and programs
– Knowledge of CMS & HHS Risk Adjustment models
– Knowledge of HEDIS and STARs
– Understanding of health care delivery system and operational processes and requirements to support a health insurance product line

Competencies, Skills, and Attributes:
– Effective collaborative and proven process improvement skills
– Strong oral and written communication skills; ability to interact within all levels of the organization
– A strong working knowledge of Microsoft Office products
– Demonstrated ability to successfully plan, organize and manage projects
– Detail oriented, excellent proof reading and editing skills
– Ability to Conceptualize
– Creates Partnerships
– Emotional Resilience
– Facilitates Change
– Management Focus

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

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