PacificSource Health Plans
Overview
Director, Risk Adjustment
role at
PacificSource Health Plans
— The Director of Risk Adjustment 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 develop, implement, and lead enterprise Risk Adjustment programs to identify risk exposures and opportunities, with a goal to optimize the program. The role ensures compliance with applicable laws, guidance, and regulations. The Director interfaces with providers, vendors, and clinical leadership to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and coding. This includes medical record retrieval, provider chart audit, and provider feedback. The role partners with internal teams such as Finance, IT, Operations, and Quality to streamline and leverage opportunities to jointly develop and implement optimization strategies. Specific accountabilities include program development, program management, vendor oversight, provider and member outreach where applicable, and oversight of business intelligence to drive performance for Medicare Advantage, Commercial ACA, and Medicaid operations.
Responsibilities
Guide the strategic direction and plan for risk adjustment, including performance metrics, timeframes and resources to drive the achievement of risk adjustment programs and recognize the value of those initiatives.
Oversee the accuracy and comprehensiveness of HCC reporting to CMS and develop, implement, and lead enterprise Risk Adjustment programs to identify risk exposures and opportunities, with a goal to optimize the program.
Support Medicare Advantage Risk Adjustment and Payment System (RAPS), Encounter Data System (EDS), Commercial Risk Adjustment EDGE Server, and CMS Reimbursement.
Monitor and analyze risk score trends. Reconcile data with financials with IT and Actuarial staff, forecast risk adjustment factors, and model impacts of potential payment changes.
Oversee development of actionable reporting and analytics related to Risk Adjustment initiatives using available technology solutions.
Oversee risk adjustment data validation audits by government agencies or external vendors; assist internal stakeholders and conduct medical record reviews to validate diagnoses.
Oversee Risk Adjustment Coding team and core functions related to 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.
Mitigate risk associated with inaccurate coding and risk scores to prevent revenue loss, CMS sanctions, or competitive disadvantages.
Support member outreach initiatives to engage members and optimize risk adjustment outcomes, facilitating appropriate and timely healthcare services.
Support provider partners through collaborative processes to optimize mutual risk adjustment outcomes, deliver actionable reports and data, support risk share contracts, and improve education related to risk adjustment.
Perform employee management responsibilities including hiring/termination decisions, coaching, performance management, and staff development.
Develop annual department budgets and monitor spending, taking corrective action as needed.
Manage vendor contracts/relationships and optimize use of internal resources.
Supporting Responsibilities
Interact with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, and Compliance; maintain collaborative partnerships with key departments.
Demonstrate strong analytical and financial skills.
Participate in strategic and internal committees to disseminate information and align with company philosophy.
Participate as a key team member in manager/supervisor meetings.
Assist in the annual Medicare Bid process.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policy and HIPAA laws concerning confidentiality and security of PHI.
Perform other duties as assigned.
Experience & Education
Work Experience:
5 years in a healthcare setting with 3 years directly related to risk adjustment; at least 3 years of experience managing teams. In-depth knowledge of risk adjustment strategies including prospective/retrospective tools, data submission guidelines, and provider engagement strategies. Vendor management experience preferred. Familiarity with pricing models by line of business 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 a health-related field and/or mathematics, statistics. Advanced degree preferred.
Environment Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Details
Seniority level:
Director
Employment type:
Full-time
Job function:
Analyst, Management, and Strategy/Planning
Industries:
Hospitals and Health Care
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Director, Risk Adjustment
role at
PacificSource Health Plans
— The Director of Risk Adjustment 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 develop, implement, and lead enterprise Risk Adjustment programs to identify risk exposures and opportunities, with a goal to optimize the program. The role ensures compliance with applicable laws, guidance, and regulations. The Director interfaces with providers, vendors, and clinical leadership to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and coding. This includes medical record retrieval, provider chart audit, and provider feedback. The role partners with internal teams such as Finance, IT, Operations, and Quality to streamline and leverage opportunities to jointly develop and implement optimization strategies. Specific accountabilities include program development, program management, vendor oversight, provider and member outreach where applicable, and oversight of business intelligence to drive performance for Medicare Advantage, Commercial ACA, and Medicaid operations.
Responsibilities
Guide the strategic direction and plan for risk adjustment, including performance metrics, timeframes and resources to drive the achievement of risk adjustment programs and recognize the value of those initiatives.
Oversee the accuracy and comprehensiveness of HCC reporting to CMS and develop, implement, and lead enterprise Risk Adjustment programs to identify risk exposures and opportunities, with a goal to optimize the program.
Support Medicare Advantage Risk Adjustment and Payment System (RAPS), Encounter Data System (EDS), Commercial Risk Adjustment EDGE Server, and CMS Reimbursement.
Monitor and analyze risk score trends. Reconcile data with financials with IT and Actuarial staff, forecast risk adjustment factors, and model impacts of potential payment changes.
Oversee development of actionable reporting and analytics related to Risk Adjustment initiatives using available technology solutions.
Oversee risk adjustment data validation audits by government agencies or external vendors; assist internal stakeholders and conduct medical record reviews to validate diagnoses.
Oversee Risk Adjustment Coding team and core functions related to 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.
Mitigate risk associated with inaccurate coding and risk scores to prevent revenue loss, CMS sanctions, or competitive disadvantages.
Support member outreach initiatives to engage members and optimize risk adjustment outcomes, facilitating appropriate and timely healthcare services.
Support provider partners through collaborative processes to optimize mutual risk adjustment outcomes, deliver actionable reports and data, support risk share contracts, and improve education related to risk adjustment.
Perform employee management responsibilities including hiring/termination decisions, coaching, performance management, and staff development.
Develop annual department budgets and monitor spending, taking corrective action as needed.
Manage vendor contracts/relationships and optimize use of internal resources.
Supporting Responsibilities
Interact with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, and Compliance; maintain collaborative partnerships with key departments.
Demonstrate strong analytical and financial skills.
Participate in strategic and internal committees to disseminate information and align with company philosophy.
Participate as a key team member in manager/supervisor meetings.
Assist in the annual Medicare Bid process.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policy and HIPAA laws concerning confidentiality and security of PHI.
Perform other duties as assigned.
Experience & Education
Work Experience:
5 years in a healthcare setting with 3 years directly related to risk adjustment; at least 3 years of experience managing teams. In-depth knowledge of risk adjustment strategies including prospective/retrospective tools, data submission guidelines, and provider engagement strategies. Vendor management experience preferred. Familiarity with pricing models by line of business 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 a health-related field and/or mathematics, statistics. Advanced degree preferred.
Environment Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Details
Seniority level:
Director
Employment type:
Full-time
Job function:
Analyst, Management, and Strategy/Planning
Industries:
Hospitals and Health Care
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