Salary Estimate: $108992.00 - $163467.20 / year
Learn more about the benefits offered for this job.
The estimate displayed represents the typical salary range of candidates hired. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role. The typical candidate is hired below midpoint of the range.

JOB SUMMARY AND QUALIFICATIONS

GENERAL SUMMARY OF DUTIES: Reporting directly to the CEO for PPMSI, this role leads all aspects of the Quality and Risk Adjustment programs for the SCCIPA network including working closely with health plan partners, the physician network and internal stakeholders to develop and implement a high-performing and compliant quality and risk adjustment program. The Manager’s primary focus is to develop, implement and oversee all quality and risk adjustment related initiatives essential to the MSO services PPMSI offers to its IPA networks. Programs include IHA Pay for Performance, CMS 5 Star, Shared Savings incentive programs and Risk Adjustment.

KNOWLEDGE, SKILLS AND ABILITIES:

• Experience in Project Management including work plan creation, budget and resourcing preferred
• Minimum 5 years in management position leading Quality and Risk Adjustment programs preferred
• Licensure: CPC, CRC and CPQH required; LVN or RN preferred
• Ability to build a high-performing quality and risk adjustment team exemplifying PPMSI and SCCIPAs Guiding Principles, and achieving the Mission of HCA
• Possess excellent written, verbal and interpersonal communication skills utilizing utmost discretion with sensitive and confidential information
• Effective and persuasive presentation skills on complex topics to leadership, internal stakeholders and physicians
• Working knowledge of risk adjustment documentation and coding requirements
• Ability to research Pay for Performance and HCC issues; read, analyze, and interpret technical procedures and regulatory requirements
• Ability to analyze health plan Quality, Shared Savings and Pay 4 Performance health plan exhibits
• Expert user of Cozeva
• Familiarity with a wide variety of EMRs
• Ability to work independently, organize time, set priorities to meet established deadlines
• Comfortable speaking, reporting and providing internal team trainings and Provider even trainings

DUTIES INCLUDE BUT NOT LIMITED TO:

Quality:

• Develops dashboard reporting by health plan to report, monitor and track performance against health plan quality measures
• Accountable for developing and executing work plan to achieve health plan quality metrics and develops performance improvement plans where indicated performance is trending off-track
• Accountable for understanding health plan incentive programs, developing a dashboard of maximum opportunity by plan and progress towards achieving incentive
• Ability to communicate and train internal teams and network physicians on current performance trend and actions to achieve health plan identified goals
• Ability to provide training sessions in small and large physician settings
• Is considered expert user of Cozeva system and data, using data to drive reporting results, improvement plans and communication/training to internal staff and network physicians.
• Ensures encounters are submitted to health plans timely, accurately and completely, identifying and implementing improved workflows as needed
• Documents the Quality program’s cross-functional workflows and ensures PPMSI stakeholders understand accountability.
• Assumes role as lead representative for SCCIPA and PPMSI on health plan JOC meetings
• Accountable for reporting results and intended action plans to PPMSI senior leadership and SCCIPA Board of Directors

Risk Adjustment:

• Accountable for leading a high-performing and compliant risk adjustment program including proper capture/recapture of HCCs
• Ability to analyze and maximize the use of Cozeva data to understand the risk burden of SCCIPA membership
• Develops a performance dashboard to track progress on Annual Wellness Visits, Members Without Visits, HCC recapture, RAF score trend and other critical program elements.
• Develops training materials and work session curriculum for physician meetings; reviews physician’s performance metrics; identifies performance opportunities and support solutions
• Leads training sessions for internal teams, such as Network Provider Representatives, to ensure Representatives are skilled in reviewing basic quality and risk adjustment dashboards and performance results
• Accountable for understanding and estimating current RAF score
• In coordination with Chief Financial Officer, analyzes and estimates risk adjustment accrual
• Develops and coordinates member outreach programs to ensure members with chronic and acute medical conditions are properly managed and monitored by the SCCIPA network, and appropriate diagnosis are captured in the medical record
• Uses Cozeva data to understand suspecting data, and ensures that information is shared w/the appropriate physician
• Accountable for successfully submitting HCCs by CMS assigned submission dates
• Accountable for ensuring rejections are worked timely and systematically, identifying and fixing root causes where needed
• Ensures supplemental file information is submitted
• Leads chart chase activities, developing a cost-effective targeted approach based on anticipated ROI
• In coordination with Network Provider Representatives, works with network physicians to gain view only access to EMRs for efficient quality and risk adjustment chart reviews
• Document program workflows and cross-functional accountability, ensuring stakeholders understand accountability and meet deliverables and timelines

WHAT YOU WILL NEED IN THIS ROLE:

EDUCATION: Bachelor Degree from a four-year college or university required
EXPERIENCE: Minimum of 3 years of previous experience in a managed care organization or other comparable experience for Quality Improvement P4P, CMS 5 Star, and CMS HCC required
Physician Services Group is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration, and graduate medical education. We lead more than 1,300 physician practices and 170+ urgent care centers. We are HCA Healthcare’s graduate medical education leader. We provide direction for over 260 exceptional resident and fellowship programs. We focus on carrying out value-added solutions. These solutions help physicians deliver patient-centered healthcare. We support HCA Healthcare’s commitment to the care and improvement of human life.
HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.
“The great hospitals will always put the patient and the patient’s family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Manager of Quality - Risk Adjustment Programs opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status