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Director, Risk Adjustment Strategies and Initiatives

Job Category:  Accounting/Finance
Department:  Risk Adjustment Strategies & Initiatives
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8522

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary


The Director, Risk Adjustment Strategies and Initiatives works closely and collaboratively with the Director, Medicare STAR Program, Medicare Medical Director, Senior Director, Medicare Operations, Chief Medical Officer, and other internal colleagues, providers and external vendors to ensure risk adjustment and 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 that organization has accurate information for Centers for Medicare and Medicaid Services (CMS) submissions and ensures compliance with all applicable regulatory agencies. Maintains and assesses the HCC and STAR landscape to identify opportunities and determine program needs, tools, etc. in order to support the organization’s objectives, physicians and other partners in these programs in understanding the Medicare payment model and STAR program. Responsible for bringing forward and developing/implementing tools or other activities to support organizational goals. Collaborates with other staff, as necessary, to finalize initiatives and provide internal, provider and other training, as needed.    

Duties

Responsible for supporting the organizational, management and development of Medicare Hierarchical Condition  Categories (HCC) program for health plan. Works closely and collaboratively with the Director, Medicare STAR Program, Medicare Medical Director, Senior Director, Medicare Operations, Chief Medical Officer, and other internal colleagues, providers and external vendors to ensure risk adjustment and 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.

                

Designs, implements and continuously monitors and refines solutions and strategies to effectively improve the capture of accurate and comprehensive risk adjustment scores and continuously improve organizations’ STAR rating. Exhibits initiative and strategic vision in identifying, developing and moving to implementation opportunities to improve organizational performance through program innovations. Develop and implement innovative and effective strategies to work with physicians and other providers to achieve organizational objectives in HCC and STAR program. Oversee and continuously improve the operations and effectiveness of the organizations’ AWE efforts. Develop, evaluate, enhance and ensure that physician and/or other incentive programs are targeted and highly effective.

 

Responsible for the oversight and monitoring and validation of coding and other data collection to ensure that organization has accurate information for Centers for Medicare and Medicaid Service (CMS) submissions. Ensures compliance with all applicable regulatory agencies. 

 

Maintains and assesses the HCC and STAR landscape to identify opportunities and determine program needs, tools, etc. in order to support the organization’s objectives, physicians and other partners in these programs in understanding the Medicare payment model and STAR program. Responsible for bringing forward and developing/implementing tools or other activities to support organizational goals. Collaborates with other staff, as necessary, to finalize initiatives and provide internal, provider and other training, as needed.  

 

Continuously monitors 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 that initiatives are implemented in a timely manner, completed on time and achieve organizational objectives. 

 

Identifies, negotiates with and manages external vendors to ensure deliverables are met in a timely manner.  

 

Troubleshoots issues with internal colleagues, committees, task forces and/or other departments to ensure that HCC and 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. 

 

Perform other duties as assigned. 

Education Required

Bachelor's Degree in Business Administration
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree in Business Administration

Experience


Required:
Minimum of 7 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 5-7 years of demonstrated leadership and management experience.

 

Minimum 5 years of experience in the healthcare setting.

 

Proven track record in managing major projects and/or programs.

Skills


Required:
Strong interpersonal and customer service skills.

 

Excellent verbal and written communication skills.

 

Strong presentation skills.

 

Proficient in Microsoft Office. 

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Medicare, Medicaid, Risk Management, Healthcare, Finance

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