Medicare Risk Adjustment Program Manager

Medicare Risk Adjustment Program Manager

eternalHealth – The Next Generation of Medicare Advantage

Healthcare is confusing, but it doesn’t need to be. As a consumer-centric HMO based in Boston, MA we are a Medicare Advantage start up that is committed to creating long-lasting partnerships with our members, our providers, and you!

About the role: As a Risk Adjustment Manager with eternalHealth you will report directly to the CFO and will play a pivotal role in assuring the accuracy, optimization, and compliance of the company’s Risk Adjustment program. The position will coordinate all operational and analytical processes and be the company’s primary subject matter, and CMS methodology, expert. The role will maintain a heavy focus on hands-on data analysis and data management. The incumbent’s work will continuously identify programmatic areas that are working well and those that are in need of improvement. Strategies will be developed, and implemented, to strengthen tactical areas. Specific duties will include calculation and forecasting of member risk scores, monitoring the impact of changing CMS methodologies, and performing complex risk adjustment-related analyses. The incumbent will also coordinate the activity of key downstream vendors that are supporting the risk adjustment program. Success will be measured via a set of key performance metrics and formal Risk Adjustment program dashboard.

We provide a unique opportunity to be a part of a health plan in its beginning stages. Our team members are flexible and able to play different roles, while staying committed to teamwork and collaboration, and passionate about sustainable change.

Responsibilities:

Lead cross-functional and operational teams toward the goal of improved risk adjustment scores.

Collaborate closely with the Compliance department to assure that the company is in full compliance with all regulatory requirements related to the risk adjustment program.

Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, CMS information system processes, and key regulatory deadlines for data submission.

Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitor and estimate the impact of any changes to the HCC model, and support actuarial resources in the estimation of risk adjustment revenue.

Perform data mining of claims and other data to identify trends, data issues, and members with missing HCCs.

Provide support to organizational strategies to ensure goals are met and propose opportunities to appropriately maximize reimbursement based on the CMS HCC model.

Provide programming support to extract and analyze data from different information systems and provide input into how data are stored and managed.

Develop tracking and monitoring mechanisms for all risk adjustment and coding programs, ensuring that key risk adjustment performance metrics and business objectives are defined and achieved.

Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy, and identification of member health conditions.

Support project management efforts, including monitoring and evaluating progress against established program timelines, project milestones, and key deliverables.

Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are being addressed in a timely manner.

Interface with other business units, internally and externally, to improve and correct data.

Oversee the analysis and interpretation of provider-specific results and risk score trend information.

Conduct analyses to develop a comprehensive understanding of providers’ risk score trends, EHR systems, and contracting arrangements to recommend and generate provider-specific engagement plans.

Assist in maintaining, and improving, the company’s analytic capabilities and action-oriented reporting in order to solve problems, provide data-driven guidance, and monitor risk adjustment performance.

Update, create and maintain business processes and technical workflow documents.

Establish, document, and maintain business process and technical resources, collaborating with multiple stakeholders at various levels throughout the company, as well as external entities, providing coordination and support as required.

Requirements:

Bachelor's degree in mathematics, actuarial science, statistics, or equivalent.

Experience working for a Medicare Advantage plan.

Working knowledge of CMS’s HCC risk adjustment methodology.

SQL experience or equivalent.

Excellent written and communication skills.

Results-oriented, strategic, and continuously striving for improvement, possessing a high degree of analytical ability and problem-solving skills.

Flexible and able to ramp-up quickly on different projects to support the team as needed in a fast-paced start-up environment.

Ability to perform job functions while maintaining compliance with all State and Federal regulations.

Great multitasking skills, strong attention to detail, great organizational skills, teamwork and a sense of personal responsibility.

Working with eternalHealth: eternalHealth is an Equal Opportunity Employer which means that we are committed to upholding discrimination-free hiring practices. As a woman-led company, and one committed to diversity at all levels, we strive for an organization of inclusion and acceptance. We are changing healthcare for the better, starting with our own diverse and passionate teams. As an eternalHealth employee you will be empowered to contribute to our teams and strategy, regardless of previous healthcare experience. Our valued team members are encouraged and expected to offer new solutions and creative input, all while keeping in line with eternalHealth’s mission, values, and compliance standards.

Accommodations: Any eternalHealth applicant will be considered based entirely on their individual qualifications. Should you require reasonable accommodation during the application process (which may include a job-related assessment) please contact us separately at HR@eternalhealth.com.