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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
The Director of Risk Assessment reports to the Vice President, Quality and Population Health and will oversee the accuracy and comprehensiveness of HCC reporting to CMS. This position manages a coordinated, cross-functional and integrated process across the organization to implement programs and streamline activities. The Director will also develop, implement, and lead enterprise Risk Adjustment programs to ensure that risk exposures and opportunities are identified timely and appropriately, with a goal to optimize the program. This job will ensure compliance to all applicable laws, guidance, and regulations.The Director will interface with providers, vendors, and clinical leadership to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and coding. Oversee risk adjustment coding team and core functions to ensure Hierarchical Condition Categories (HCC) coding guidelines are met using industry best practice. This includes medical record retrieval, provider chart audit, and provider feedback.This individual will partner with internal teams such as Finance, IT, Operations, and Quality to streamline and leverage opportunities to jointly develop and implement optimization strategies. Specific accountabilities within the job include program development, program management, vendor oversight, provider and member outreach where applicable, and oversight of the business intelligence necessary to drive optimal performance for the Medicare Advantage, Commercial Affordable Care Act, and Medicaid business.

Essential Responsibilities:

• Guide the strategic direction and plan for risk adjustment including performance metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives.
• Oversee the accuracy and comprehensiveness of HCC reporting to CMS and develop, implement, and lead enterprise Risk Adjustment programs to ensure that risk exposures and opportunities are identified timely and appropriately, with a goal to optimize the program.
• Support of the Medicare Advantage Risk Adjustment and Payment System (RAPS), Encounter Data System (EDS), Commercial Risk Adjustment EDGE Server and Centers for Medicare & Medicaid (CMS) Reimbursement.
• Monitor and analyze risk score trends. Work with IT and Actuarial staff to reconcile data with financials, forecast risk adjustment factors, and model impacts of potential payment changes.
• Oversee development of actionable reporting and analytics with respect to Risk Adjustment initiatives using appropriate and available technology solutions.
• Oversee risk adjustment data validation audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and conducting medical record reviews to validate diagnoses.
• Oversee Risk Adjustment Coding team and core functions pertaining to Hierarchical Condition Categories (HCC) coding, medical record retrieval, provider chart audit, and provider feedback.
• Oversee the development and implementation of provider engagement activities related to risk adjustment including performance improvement strategies to support complete and accurate diagnosis capture.
• Accountability for mitigating risk associated with inaccurate coding and risk scores which could result in lost revenue, potential CMS sanctions or penalties, and disadvantages relative to competitors.
• Supports member outreach initiatives designed to engage members, optimize risk adjustment outcomes, and positively affect the member through facilitating appropriate and timely healthcare services.
• Support key provider partners through collaborative processes aimed to optimize mutual risk adjustment outcomes, delivering actionable reports and data, support risk share contracts, and facilitate opportunities to improve general education related to risk adjustment.
• Performs employee management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.
• Manages vendor contracts/relationships and looks for effective ways to reduce use of vendors and build internal knowledge/use internal resources.

Supporting Responsibilities:

• Interact with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, and Compliance. Coordinate business activities by maintaining collaborative partnerships with key departments.
• Strong analytical/financial skills.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Actively participate as a key team member in manager/supervisor meetings.
• Assists in annual Medicare Bid process.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: 5 years experience in a healthcare setting with 3 years experience directly related to risk adjustment required. At least 3 years experience managing teams required. Must have in depth knowledge of risk adjustment strategies including prospective tools, retrospective tools, data submission guidelines, and provider engagement strategies. Experience managing vendor relationships preferred. Familiarity with pricing models for each line of business is highly preferred. Experience influencing and managing value based contracts with provider groups also highly preferred. Experience with Medicaid, Medicare and Commercial health services operations, strategic planning and system design in health plans is preferred.
Education, Certificates, Licenses: Bachelor’s Degree in health related field and/or mathematics, statistics. Advance degree preferred.
Competencies:
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Partnerships
Customer Focus
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:
Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning
Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times

Essential Responsibilities:

• Guide the strategic direction and plan for risk adjustment including performance metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives.
• Oversee the accuracy and comprehensiveness of HCC reporting to CMS and develop, implement, and lead enterprise Risk Adjustment programs to ensure that risk exposures and opportunities are identified timely and appropriately, with a goal to optimize the program.
• Support of the Medicare Advantage Risk Adjustment and Payment System (RAPS), Encounter Data System (EDS), Commercial Risk Adjustment EDGE Server and Centers for Medicare & Medicaid (CMS) Reimbursement.
• Monitor and analyze risk score trends. Work with IT and Actuarial staff to reconcile data with financials, forecast risk adjustment factors, and model impacts of potential payment changes.
• Oversee development of actionable reporting and analytics with respect to Risk Adjustment initiatives using appropriate and available technology solutions.
• Oversee risk adjustment data validation audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and conducting medical record reviews to validate diagnoses.
• Oversee Risk Adjustment Coding team and core functions pertaining to Hierarchical Condition Categories (HCC) coding, medical record retrieval, provider chart audit, and provider feedback.
• Oversee the development and implementation of provider engagement activities related to risk adjustment including performance improvement strategies to support complete and accurate diagnosis capture.
• Accountability for mitigating risk associated with inaccurate coding and risk scores which could result in lost revenue, potential CMS sanctions or penalties, and disadvantages relative to competitors.
• Supports member outreach initiatives designed to engage members, optimize risk adjustment outcomes, and positively affect the member through facilitating appropriate and timely healthcare services.
• Support key provider partners through collaborative processes aimed to optimize mutual risk adjustment outcomes, delivering actionable reports and data, support risk share contracts, and facilitate opportunities to improve general education related to risk adjustment.
• Performs employee management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.
• Manages vendor contracts/relationships and looks for effective ways to reduce use of vendors and build internal knowledge/use internal resources

Supporting Responsibilities:

• Interact with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, and Compliance. Coordinate business activities by maintaining collaborative partnerships with key departments.
• Strong analytical/financial skills.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Actively participate as a key team member in manager/supervisor meetings.
• Assists in annual Medicare Bid process.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned