Alignment Healthcare
Director, RADV Program Analytics & Risk Reporting
Alignment Healthcare, Orange, California, United States, 92613
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Reporting to the VP of Medicare Advantage RADV Programs, the Director of RADV Programs, Analytics & Reporting, is responsible for managing and overseeing the development of RADV risk exposure models, extrapolation impact analysis, and audit forecasting tools. This individual ensures the integrity of audit data, provides leadership on data governance, and supports executive decision-making with accurate risk metrics.
Job Responsibilities:
Cross-functional collaboration: Working closely with other departments (Risk Adjustment Operations, Finance, DTS, Compliance, etc.) to ensure accurate data for financial risk modeling. Ensure data governance and integrity for all risk adjustment and HCC related metrics. Translate business requirements into specifications that will be used to implement the required BI Solutions and dashboards. Work with data engineers to ensure that data sets feeding the analytics platforms are tuned for optimal performance. Work with business stakeholders to define and improve standardized and ad-hoc analytics/reporting capabilities. Design, model, develop, and optimize stored procedures to meet data management and data reporting objectives. Oversee the reconciliation of audited HCCs against submitted claims data and standard CMS files. Direct analysts in data validation, dashboard development, and audit metrics reporting. Present audit trend analysis to leadership and regulatory committees. Track progress and performance metrics; escalate risks to leadership as needed. Develop and maintain standard operating procedures (SOPs & P&Ps) for CMS HCC/risk adjustment models and RADV analytics workflows. Evaluate, implement, and optimize performance management and analytics tools to streamline processes and improvement and user experience.
Supervisory Responsibilities:
Perform management responsibilities including but not limited to involvement in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct, and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
Job Requirements:
Experience:
Required: A minimum of 7 years' experience in data science or a related field, with at least 5 years in a leadership role managing data science teams.
Preferred: Experience in a large health system strongly preferred
Education:
Required: Bachelor's degree in computer science, IT or equivalent experience
Preferred: Microsoft SQL Server, Power BI, Python, or Azure Certification/Experience
Training:
Required:
Preferred:
Specialized Skills:
Required: Extensive experience working with large, complex data sets, including clinical and healthcare data, and proficiency in data integration from various sources.
Preferred:
Licensure:
Required:
Preferred:
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $172,364.00 - $258,547.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.
*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.
Reporting to the VP of Medicare Advantage RADV Programs, the Director of RADV Programs, Analytics & Reporting, is responsible for managing and overseeing the development of RADV risk exposure models, extrapolation impact analysis, and audit forecasting tools. This individual ensures the integrity of audit data, provides leadership on data governance, and supports executive decision-making with accurate risk metrics.
Job Responsibilities:
Cross-functional collaboration: Working closely with other departments (Risk Adjustment Operations, Finance, DTS, Compliance, etc.) to ensure accurate data for financial risk modeling. Ensure data governance and integrity for all risk adjustment and HCC related metrics. Translate business requirements into specifications that will be used to implement the required BI Solutions and dashboards. Work with data engineers to ensure that data sets feeding the analytics platforms are tuned for optimal performance. Work with business stakeholders to define and improve standardized and ad-hoc analytics/reporting capabilities. Design, model, develop, and optimize stored procedures to meet data management and data reporting objectives. Oversee the reconciliation of audited HCCs against submitted claims data and standard CMS files. Direct analysts in data validation, dashboard development, and audit metrics reporting. Present audit trend analysis to leadership and regulatory committees. Track progress and performance metrics; escalate risks to leadership as needed. Develop and maintain standard operating procedures (SOPs & P&Ps) for CMS HCC/risk adjustment models and RADV analytics workflows. Evaluate, implement, and optimize performance management and analytics tools to streamline processes and improvement and user experience.
Supervisory Responsibilities:
Perform management responsibilities including but not limited to involvement in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct, and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
Job Requirements:
Experience:
Required: A minimum of 7 years' experience in data science or a related field, with at least 5 years in a leadership role managing data science teams.
Preferred: Experience in a large health system strongly preferred
Education:
Required: Bachelor's degree in computer science, IT or equivalent experience
Preferred: Microsoft SQL Server, Power BI, Python, or Azure Certification/Experience
Training:
Required:
Preferred:
Specialized Skills:
Required: Extensive experience working with large, complex data sets, including clinical and healthcare data, and proficiency in data integration from various sources.
Preferred:
Licensure:
Required:
Preferred:
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $172,364.00 - $258,547.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.
*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.