Position Description:

Capital Blue Cross has an exciting opportunity for a position to join our award-winning organization. Since 2014, Capital Blue Cross has scored higher than all health insurance providers publicly measured in the American Customer Satisfaction Index (ACSI) and is proud to be named a Best Places to work in PA, Harrisburg Magazine’s Simply the Best, and Highest Member Satisfaction J.D. Power Award.

The Risk Adjustment Program Manager is responsible of the development, management, and execution of Capital’s Risk Adjustment Program driving high quality and performance outcomes thru improvements on our Medicare and Commercial end-to end clinical documentation, reporting, and submissions.

This role provides strategic and tactical direction in collaboration with the Stars & Risk Adjustment Sr. Director and Medical Director. Function as a Risk Adjustment subject matter expert- manage work plans- perform analysis- market research, as well work with cross-functional teams in the development and implementation of efficient and effective standards, tactics, initiatives and systems, etc. to support ongoing improvements and ensure compliance to prevent, detect and mitigate compliance risks.

Responsibilities and Qualifications:

• Guide and oversees the creation- implementation- and monitoring process of the Risk Adjustment Program strategy, objectives, tactic, and initiatives to drive a year over year quality of care improvements- appropriate reimbursement, and compliance with CMS mandates, regulations, and audits.
• Manage Risk Adjustment Program activities including: process flows and documentation- project management, managing vendor execution, coordinating all submission and reconciliation with internal and external stakeholders.
• Acts as subject matter expert, maintain up-to date knowledge and interpret applicable federal and state regulations, CMS guidelines and requirements, and Medicare and ACA models transferring knowledge to leadership and cross-functional teams- etc.
• Lead the development of analytics, reports, tools, workflows, and metrics to ensure that the accuracy and completeness of retrieval, coding and documentation is improved
• Lead data review, monitoring process, and completion of submissions for Medicare and Commercial/ACA products (e.g., RAPS/EDPS submissions).
• Lead the implementation- manage on-going vendor activities, oversight, etc. (operations and analytics tools).
• Develop and manage tracking tools, dashboards, and metrics for monitoring progress the Risk Adjustment Program. Complete on-going performance status reports including key successes, challenges and recommendations by contract/line of business and communicate to leadership Drive innovative initiatives that address low-performing measures. Lead the monitoring process and work with business owners to ensure goals are achieved. Lead Risk Adjustment Work Groups and deliverables in collaboration with Stars & Risk Adjustment Sr. Director and Medical Director- etc.
• Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies.
• Ensure the coordination of processes, protocols and data flow between risk adjustment and care management resulting in appropriate follow of care and quality of care improvement’s activities.
• Build strong relationships across Capital teams, provider network, vendors, and customers. Actively participant on engagement activities with providers, customers, and vendors in support of the Risk Adjustment Program. Collaborate in building materials, analysis, reports, and presentations for Committees- performance meetings, trainings, newsletter, etc.
• Lead the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability.
• Lead, develop, and mentor the Risk Adjustment team.

Education and Certifications:

• Prefer bachelor's in data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics, Public Health or Health-related Sciences or Health Administration.

Experience:

• 5 years' experience overseeing and driving Risk Adjustment and data analytics performance.
• 7 years' experience working with Medicare Advantage Plans experience.
• 8 years' experience working with several of the following methodologies: Project management, quality of care improvement, process improvements, financial analysis.
• 3 years' experience leading a team of direct reports, vendors, and relationships at all levels of management, mostly mid-senior level.
• Advanced skills on MS Access- Excel- SAS- Power BI, SQL, and other query/reporting tools.
• Mastery of CMS HCC Risk Adjustment coding and data validation requirements.
• Proven knowledge and understanding of ICD-10-CM coding guidelines, understanding of medical terminology, and clinical practice and processes.
• Strong understanding of the Medicare and ACA Risk Adjustment models.
• Experienced leading initiatives, projects, and process changes at enterprise level.

Skills:

• Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand. Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach. Ability to influence and persuade people to collaborate and execute toward a common goal.
• Strong organization and documentation- attention to details- ability to handle multiple projects and tasks simultaneously- time management meeting deadlines- even under pressure.
• Successful record of managing multiple projects with excellent results- meeting desired outcomes and goals. Eager to work with sense of urgency aligned with priorities- overcome obstacles, if needed seek for support early driving the best results to positive impact the Company and team goals.
• Ability to think analytically to resolve issues; solution-focused mindset; creative- innovative- and compliance thinker.
• Adaptability to an agile and dynamic work environment.
• Ability to prioritized tasks and shift readily between “big picture” and small-but-critical details. Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions.
• Advanced skills on MS Access, Excel, SAS, Power BI, SQL, and other query/reporting tools
• Strong proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Project Management tools, Teams/WebEx/ZOOM.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

About Us: Capital Blue Cross is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. As a partner in the community’s health for over 80 years, Capital Blue Cross offers employees excellent pay, bonus opportunities, benefits, health and wellness incentives, opportunities for career advancement and community involvement, and work-life balance. In return, every member of our workforce plays an important part in something much bigger: working together and making a difference every day to improve the health and well-being of our members and the communities in which they live.