Manager of Risk Adjustment

Company: Neighborhood Health Plan of Rhode Island
Job Title: Manager of Risk Adjustment
Reports to: CFO
Location: Smithfield, RI

Neighborhood Health Plan of Rhode Island has retained Morgan Consulting Resources, Inc. to conduct the search for their Manager of Risk Adjustment. This opening represents an exceptional opportunity to join an award winning, Community Health Center based organization committed to ensuring access to high quality, cost-effective health care to over 200,000 members. This position is based in Smithfield, RI, a suburb of Providence.

About the Organization:

Neighborhood Health Plan of Rhode Island (Neighborhood) is a non-profit HMO that was founded in 1994 to make sure everyone in the state has access to high-quality, low-cost health care. Neighborhood has been ranked as one of the top Medicaid health plans in America for the past twelve years. Neighborhood also recently extended its great service, benefits and value to individuals and businesses through HealthSource RI – the state’s health insurance exchange. For more information about the organization, please visit: https://www.nhpri.org/Home.aspx.

About the Position:

Reporting to the CFO, the Manager of Risk Adjustment will be responsible for revenue optimization through the development, implementation and oversight of Neighborhood’s risk adjustment initiatives to include management of: coding programs and processes, data analysis and submission, accounting requirements, quality assurance, provider engagement and training, vendor activities, and evaluation/development of policies and procedures to ensure compliance with all Centers for Medicare and Medicaid (CMS) and Rhode Island regulatory guidelines.

We are looking for a strategic and collaborative leader with a strong understanding of CMS data and risk adjustment processes including RAPS, EDPS, Edge Server and RADV Audit, as well as experience managing CMS Risk Adjustment rules and regulations for Medicare Advantage and Commercial programs. The ideal candidate will operate with a high level of accountability and have the interpersonal skills needed to build and maintain strong relationships, both internally and externally. Those best suited for this role will possess excellent analytical, problem solving and negotiating skills.

Key Duties and Responsibilities:

  • Collaborate with key internal stakeholders (Quality Analytics, Performance Improvement, Medical
  • Management, Provider Engagement and Contracting, Finance, and Compliance) to develop, implement and continually refine prospective and retrospective diagnosis coding programs and provider support.
  • Develop, oversee and adapt infrastructure (processes, systems, talent) to support an effective risk adjustment program as CMS evolves the model and guidance.
  • Collaborate with Neighborhood departments and vendors to ensure timely, accurate and complete submission of risk adjustment data to CMS and ensure reconciliation of plan payments.
  • Responsible for the development and reconciliation of risk adjustment revenue and expense accruals each month.
  • Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
  • In collaboration with internal departments as appropriate, develop and oversee the execution of strategies, programs and plans to engage contracted medical group physicians in proper assessment, coding and documentation of all members, complete submission of data, and engagement in company programs that support these efforts.
  • Develop and implement programs for provider training and education on HCC risk adjustment, proper medical record documentation and diagnosis coding accuracy.
  • Collaborate with vendors to project and monitor the impact of coding programs on CMS revenue for budgets and plans.
  • Management of professional level staff.

Qualifications:

Required:

  • Bachelor’s Degree in Finance, Business or health related field.
  • 5 years’ experience managing CMS Risk Adjustment rules and regulations for Medicare Advantage and Commercial programs in a health plan setting.
  • Experience with CMS Risk Adjustment processes including RAPS, EDPS, Edge Server, and RADV Audit.
  • Strong understanding of medical terminology such as diagnosis codes (ICD-10) and other claims coding topics such as CPT, HCPCS and related Hierarchical Condition Coding (HCC) methodologies.
  • Experience with vendor supported Risk Score Accuracy programs.
  • Strong supervisory, communication, and interpersonal skills.

Preferred:

  • Master’s Degree.
  • CPT coding certification.
  • SQL knowledge and ability to create queries for reconciliation.
  • Knowledge of Medicare payment methodologies and Commercial Health Insurance Market reimbursement methodologies, rate setting, member cost share, etc.

If you or someone you know has the qualifications outlined, I’d love to set up a time to talk. Thank you so much for your time.

Lynn Barboza, Executive Recruiter
Morgan Consulting Resources, Inc.
lynn@morganconsulting.com

 

 

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