Director, Risk Adjustment

Job Description

Position Purpose: The Director, Risk Adjustment is a key strategic leader responsible for driving the Risk Adjustment for various lines of business and achieving related revenue targets. This includes identifying opportunities to improve completeness as well as accuracy of risk adjustment data submitted to CMS and HHS. This leader is also responsible for the development, analysis and reporting of key risk adjustment metrics, as well as overseeing analyses of new legislation and regulations regarding Risk Adjustment and assessing the impact of any changes in the programs.
Partner with executive leadership to plan the strategic direction of Risk Adjustment initiatives to facilitate achievement of the business goals and objectives and success criteria for the future. Evaluate and oversee the development and implementation of CMS and HHS risk adjustment program changes. Incorporate changes and requirements into strategy.
Coordinate with appropriate functional areas including Medical Management, Quality, Pharmacy, Operations, etc. as it relates to Risk Adjustment, Clinical Risk Groups and Quality initiatives. Use analytics to define Risk Adjustment focus. Identify areas to increase quality and maximize opportunities.
Direct the development of key analytics and data to support Risk Adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization. Educate internal and external stakeholders on changes in regons and the critical nature of risk adjustment and recommend areas of process improvement.
Maximize return on investment in Risk Adjustment operations by reducing reliance on vendors and increasing validity of data submissions.
Maintain and oversee an effective and optimal Risk Adjustment submission process and Quality Assurance Program. Monitor, measure and communicate Risk Adjustment performance and submission quality relative to the various program strategies.
Develop performance targets for both internal and external constituents. Ensure that performance targets are set and included in contracts where appropriate. Track progress against stated goals and drive to attainment.
Verify that data submissions are complete and accurate and that the pertinent authority has confirmed receipt. Serve as the subject matter expert in projects and initiatives. Drive Risk Adjustment best-practices across all lines of business.
Ensure alignment and attainment of Risk Adjustment goals with business owners. Develop and implement employee training and provider outreach programs, as needed, to improve Risk Adjustment performance.