Director, Quality Risk Adjustment Operations

Job Summary:

The Director, Quality Risk Adjustment Operations manages the operational execution of insourced and outsourced risk adjustment programs for all products: MA/MMP/DSNP (Hierarchical Condition Category/HCC), Marketplace (Department of Health & Human Services/HHS), Medicaid (CDPS-Rx), and expansion products by developing and implementing operational processes and program management to ensure the members' risk scores accurately reflect their health status profile and CareSource is reimbursed appropriately.

Essential Functions:

• Develops and implements operational processes and procedures to ensure the accuracy and completeness of Quality Risk Adjustment (QRA) data, and to ensure compliance with all applicable regulations and guidelines
• In alignment with the QRA department's strategy, implements operational tactical plans to achieve revenue objectives and Quality and Affordability Initiatives (QAIs)
• Builds and directs insourced operational team and processes, managing administrative expenses while improving risk score accuracy
• Provides subject matter expertise (SME) and business requirements to develop technology and processes that are scalable and configurable for growth and business process improvement
• Directs outsourced vendor execution using Key Performance Indicators (KPIs) within approved budget parameters
• Applies innovation to improve risk adjustment outcomes through industry networking, internal ideation, and vendor due diligence
• Drives contracting working with Sourcing for new vendors, including negotiating and renegotiating fees and service level agreements (SLAs)
• Develops and maintains policies, procedures, and documentation of CareSource's QRA operational processes
• Analyzes and monitors operational QRA reports to ensure operational productivity and program goals are met weekly, monthly quarterly, and annually
• Collaborates with QRA analytical team to develop monthly administrative expense and revenue accruals related to the risk adjustment operational programs
• Recruits, develops, and motivates qualified staff; initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions
• Perform any other job-related instructions, as requested

Education and Experience:

• Bachelor of Science degree in Finance, Business Administration, or Clinical related field or equivalent work experience is required
• Master of Business Administration (MBA), or other related graduate degree is preferred
• Ten (10) years of managed care plan and/or vendor experience, to include at least five (5) years in Risk Adjustment operational program management required
• Five (5) years of management experience is required

Competencies, Knowledge and Skills:

• Knowledgeable of Medicaid and CMS/HHS risk adjustment programs, timelines, and governmental regulations
• Knowledgeable of ICD-10 and CPT codes (certified coding certification preferred)
• Proficient in project management disciplines, MS Project or equivalent project management tools
• Ability to use data to drive decision-making and execution is necessary
• Strong presentation skills with proficiency in MS PowerPoint and all MS Office applications required
• Effective oral, written and interpersonal communication skills
• Ability to manage, develop, motivate and reward team members
• Ability to effectively report data, analyze facts, and exercise sound business judgment when making recommendations
• Ability to analyze financial, clinical, and operational data to perform root cause analysis and to develop and implement action plans to mitigate risks
• Ability to work independently
• Critical listening and thinking skills

Licensure and Certification:

• Project Management Professional (PMP) preferred
• Coding certifications preferred (CPC, CRC, RHIT, RHIA)

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to travel occasionally

Compensation Range:
$130,300.00 - $228,100.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies: