Manager, Revenue Data Operations
Who We Are
Founded in 1987, the Health Plan of San Mateo (HPSM) is a managed care plan that offers health coverage and a provider network to San Mateo County’s underserved Medi-Cal population. We have a culture focused on kindness, advocacy, and pride in our mission.
We believe that Healthy is for Everyone—and we fight to make that possible.
Over 90% of our employees say that they take pride in the work they are doing at HPSM. Come find out why we love to do what we do.
Reporting to the Director of Financial Planning & Analysis, the Manager of Revenue Data Operations is responsible for developing and leading cross-functional internal and external operations in support of organizational revenue integrity, including Encounter Data, Medicare Risk Adjustment, and other revenue data related functions or programs with the goals of understanding and mitigating risk exposure and pursuing accuracy and completeness in revenue data used by HPSM’s governmental regulators.
Essential Functions will include:
- Facilitate staff results and development by communicating job expectations, planning, monitoring and appraising job results; coaching, counseling, and implementing corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity
- Identify and encourage staff growth and development opportunities and support continuous team and department learning and improvement efforts; complete performance evaluations in a comprehensive and timely manner
- In collaboration with the Revenue Data Operations unit staff, other units within Financial Planning & Analysis, and other impacted departments, develop and pursue strategic goals that align with organizational
- Provide accountability for the business support and operational and financial outcomes of revenue data operations across departments and lines of business, including but not limited to Medicare and Medi-Cal encounter data and Medicare Risk
- In collaboration with Finance, Claims, Information Technology (IT), Provider Services, Pharmacy and other relevant business owners, develop and implement business support functions for all encounter data activities, including but not limited to all submission activities (including chart review and supplemental data), external regulator reporting oversight, internal monitoring and reporting, error management, financial valuation, provider data specifications and network expectations, and claims data intake
- Facilitate cross-functional relationships to ensure that revenue data operations are integrated across the organization; work with department and team leaders to develop initiatives or programs to expand, streamline, and leverage revenue-related
- Ensure revenue data integrity by identifying discrepancies between HPSM data and that received from a State or Federal funding agency and analyzing encounter data for opportunities to improve completeness and
- Manage risk adjustment related activities and compliance, including but not limited to prospective (e.g., home assessments), retrospective (e.g., chart collection & review), and concurrent (e.g., chart quality oversight) programs, Risk Adjustment Data Validation (RADV) preparation and support, and member and provider level risk score trending and reporting (e.g., enrollment mix, special status, etc.), to ensure achievement of accurate, timely, and expected
- Model and monitor risk-adjusted revenue and identify trends and variance by line of business; conduct mitigation activities as needed; provide reporting and analysis of revenue results to assist in product development strategy and bid or rate development
- Identify and apply best Medicare Risk Adjustment practices to ensure efficacy and accuracy of risk adjustment programs; maintain risk adjustment policies and
- Oversee and manage external vendor relationships for performance and compliance; conduct thorough and fair vendor need identification and procurement processes with special attention to reducing duplication of plan effort/resources.
- Identify and implement appropriate analytic approaches, methodologies, and support Identify opportunities for automation in processes and opportunities to integrate additional data sources or tools allowing for new or improved functionality.
- Maintain knowledge of all relevant legislative and regulatory mandates and ensure that all activities are in compliance with these requirements; participate in external learning collaboratives or advocacy related to revenue data
The following represents the typical qualifications, skills, and knowledge necessary to be eligible for this position.
Education and Experience:
- Bachelor’s Degree in Business Administration, Finance, Health Care Management, or related Master’s Degree or above is strongly preferred.
- Five (5) to seven (7) year’s experience in encounter data, risk adjustment, claims, revenue cycle management, and/or financial-facing member or provider programs and data operations in a managed care, health plan, or medical environment.
- Prior management experience of at least two (2) years in a supervisory
- Principles and methods of planning and directing operations and data submission activities while maintaining compliance with encounter data and Medicare risk adjustment
- Medicaid (preferably Medi-Cal) and Medicare reimbursement and revenue methodologies with an emphasis on understanding and impacting revenue though data accuracy and completeness improvement
- Healthcare delivery system and the key attributes of claims and other service and payment delivery data (e.g., claim types, procedure and revenue codes, date of service, enrollee and provider characteristics, ) or encounter data submission formats (e.g., 837, RAPS, etc.).
- Vendor procurement and management principles and
- Continuous improvement strategies and root cause analysis methodologies
- Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel,
- Communicate effectively across mediums and with a high level of attention to
- Effectively coach, lead and develop a multidisciplinary staff and engage organizational stakeholders
- Work collaboratively with others to provide high-quality customer service and deliverables with a focus on department, organizational, and regulator driven priorities and deadlines
- Function as part of a cohesive department management team and support team decisions
- Present analyses to stakeholders in a clear, concise, and accurate manner to advance projects and transform data into actionable outcomes
- Anticipate customer needs and proactively develop solutions to meet them
- Maintain and enhance systems and technologies to collect information
- Report results to management using dashboards, metrics, and visual aids
- Translate complex data, processes, and financial information for a variety of stakeholders
- Commit to high-quality work, analytic methodologies, deliverable standards with a positive attitude and constructive approach
- Identify opportunities for continuous team and department improvements
Compensation and Benefits
- Starting Compensation Range: Depending on Experience
How to Apply
- Application Process: To apply, submit a resume, and cover letter to email@example.com.
The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.