Director, Risk Adjustment Strategies and Initiatives

Job Summary

The Director, Risk Adjustment Strategies and Initiatives develop strategic plans, drives change and influence critical business outcomes; oversees operations, ensuring efficiency and effectiveness.  This position leads the design, execution, and continuous improvement of enterprise risk adjustment strategy to optimize accurate diagnosis capture, support compliant revenue integrity, and improve clinical documentation practices across lines of business. 

The Director works closely and collaboratively with the cross-functional teams and external vendors to ensure risk adjustment and Medicare STAR strategies, including Annual Wellness Exams (AWEs) are well-coordinated and executed in a timely and efficient manner and data is collected in a timely manner. The position is responsible for the oversight and monitoring and validation of coding and other data collection to ensure the organization has accurate information for regulatory submissions and ensures compliance with all applicable regulatory agencies. Maintains and assesses risk adjustment and Medicare STAR landscape to identify opportunities and determine program needs, tools, etc. to support the organization’s objectives, physicians and other partners in these programs in understanding the Medi-Cal, ACA and Medicare payment models and Medicare STAR program.

Responsible for bringing forward and developing/implementing tools or other activities to support organizational goals. Collaborate with other staff, as necessary, to finalize initiatives and provide training to internal and external stakeholders as needed.                        

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  

Duties

Responsible for supporting the organizational, management and development of risk adjustment programs for L.A. Care’s risk adjusting lines of business (LOB). Conduct strategic planning to utilize resources to meet current and future departmental and Enterprise-wide goals.

Develop and execute a risk adjustment strategy aligned to organizational goals, regulatory requirements, and performance targets. Lead cross-functional initiatives to improve diagnosis accuracy, coding capture, and documentation quality across settings. Establish and manage program governance, workplans, timelines, and reporting for risk adjustment initiatives.

Design, implement, and monitor and refine solutions and strategies to effectively improve the capture of accurate and comprehensive risk adjustment scores and continuously improve organizations’ STAR rating. Exhibit initiative and strategic vision in identifying, developing and moving to implementation opportunities to improve organizational performance through program innovations. Identifies and actualizes enhancements to support company vision.

Develop and implement innovative and effective strategies to work with physicians and other providers to achieve organizational objectives in risk adjustment and STAR programs. Oversee and continuously improve the operations and effectiveness of the organizations’ AWE efforts. Develops, evaluates, enhances and ensures physician and/or other incentive programs are targeted and highly effective.

Direct programs supporting compliant coding and documentation practices, including prospective, concurrent, and retrospective review models. Responsible for the oversight and monitoring and validation of coding and other data collection to ensure the organization has accurate information for regulatory submissions. Drive standardization of chart review processes and quality controls to ensure consistency and compliance. Ensure compliance with all applicable regulatory agencies.

Maintain and assess the risk adjustment and Medicare STAR landscape to identify opportunities and determine program needs, tools, etc. to support the organization’s objectives, physicians and other partners in these programs in understanding the risk adjustment payment model and Medicare STAR program.

Responsible for bringing forward and developing/ implementing tools or other activities to support organizational goals. Collaborate with other staff, as necessary, to finalize initiatives and provide internal, provider and other training, as needed. 

Duties Continued

Manage risk adjustment vendors (chart retrieval, coding, suspecting, analytics tools, provider education) including performance SLAs and outcomes.  Identifies, negotiate with and manage external vendors to ensure deliverables are met in a timely manner. Manage budgets and resources effectively.

Partners with analytics teams to identify opportunities through data mining, predictive suspecting, and performance segmentation. Translate complex data into actionable recommendations and executive-level updates.

Lead discussions on policy operationalization and oversee key policy perspective sharing. Prepare briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's regulatory position and policy.  Develops regulatory position and policy based on research and evidence.

Monitor the effectiveness of initiatives and activities through the development and maintenance of a comprehensive HCC/AWE operations dashboard and other management reports, as developed and implemented.  Ensures timely and accurate reports provided to leadership monthly.

Manages multiple initiatives and projects and uses project management techniques, including project plans, plan or activity oversight, schedules, task force and/or other meetings, timelines, etc., to ensure initiatives are implemented in a timely manner, completed on time and achieve organizational objectives.

Troubleshoots issues with internal colleagues, committees, task forces and/or other departments to ensure risk adjustment and Medicare STAR activities are pursued assertively and barriers to performance are identified quickly and solutions developed and implemented. Resolves and/or escalates critical issues that impact timelines or success in a timely manner.

Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 8 years of experience in risk adjustment, and strong knowledge of Centers for Medicare and Medicaid Services (CMS) Risk Adjustment and ICD-10 coding requirements and regulations.

At least 6 years of leadership and management experience.         

At least 5 years of experience in the healthcare setting.

Experience leading teams, projects, initiatives, or cross-functional groups

 Preferred:

Experience in ACA risk adjustment

 Experience in California Medi-Cal risk adjustment

Skills

Required:

Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment

Excellent written, verbal communication, and negotiation skills.

Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

Demonstrated ability to make sound and timely decisions.

Demonstrated ability to adapt to changing situations and adjust strategies accordingly

Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.

Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Strong understanding of risk adjustment operations: chart retrieval, coding, provider education, suspecting, reconciliation, and audit preparation.

Proven ability to lead cross-functional initiatives and influence stakeholders at multiple levels.

Strong presentation skills.

Proficient in Microsoft Office.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information