Enterprise Risk Adjustment and Encounters Program Manager II

Job Summary

The Enterprise Risk Adjustment and Encounters Program Manager (PM) II oversees one or more programs ensuring that the department management and key stakeholders define the program goals. This position oversees and administers all phases of programs from inception to finish such as Risk Adjustment and Encounter-related programs for Medicare, Medi-Cal and Commercial lines of business, California Advancing and Innovating Medi-Cal (CalAIM) Programs, Directed Payment Programs, Subcontractor Medical Loss Ratio (MLR), Prop 56/Targeted Rate Increase (TRI), and other programs at the discretion of the leadership team. This position implements work scope, oversees funding, provides program/project planning, and administration. Develops operational policies and procedures.

This position works closely with cross-functional teams to conceptualize solutions, organize and align teams for data regression testing, track and monitor system test cases, and user acceptance deliveries and drive towards meeting risk adjustment key performance indicator (KPI) metrics and reports for all three lines of business (Commercial, Medicare and Medi-Cal).

The PM II standardizes technical meetings and data discussions. This position sets accountability by tracking progress, resolving dependencies, identifying issues, evaluating risks, and communicating with cross-functional stakeholders to ensure an efficient and consistent execution. The PM II engages the team to continue to support, test and upgrade multi-functional software programs for risk adjustment data collection and processing. 

The PM II executes the high-impact risk adjustment and encounters system implementations to continuously improve data and reporting processes. This position ensures to increase the effectiveness of encounter data operations, risk adjustment programs and operations infrastructure. The PM II also serves as the program manager for committees. This position is responsible for developing program assessment protocols for effectiveness and quality improvement. The PM II maintains the program standards of quality and performance. This position oversees the program budget for maximum utilization of resources.

Duties

Oversee cross-program activities and ensure the programs achieve their goals. Formulate, organize and monitor inter-connected programs. Develop and control deadlines and activities. Monitor and evaluate Key Performance Indicator (KPI) and return on investment (ROI). Support cost accounting activities and collaboration with other stakeholders as necessary.

Provide guidance to staff. Partner with stakeholders to drive program initiatives improving operating performance such as yield improvements and labor efficiency, balance sheet optimization, and total cost reductions.

Direct all phases of programs from inception through completion. Set priorities and milestones for individual projects and team initiatives within the program. Support the implementation and maintenance of internal procedures, policies, and practices to ensure proper safeguarding of L.A. Care’s assets.

Develop and implement annual work plans; ensure timely and high-quality reviews and submissions of deliverables; prepare scopes of work and monitor service delivery. Participate and recommend in setting program goals and objectives. Ensure team members have the resources needed to meet their goals. Review, edit, and contribute to technical deliverables and manage field assignments as required.

Provide recommendations on financial management of assigned programs including developing, tracking, and updating budgets; monitoring monthly projections and actuals; obligated funds notifications; anticipate budget modifications and other financial matters. Plan, develop, and implement strategies for generating funding and/or resource opportunities for program activities.

Provide program management and partnership with technical project team. Communicate and document concise program timelines, risks, escalation path, roles/responsibilities, and accountabilities. Facilitate technical meetings for risk adjustment for all product lines, capturing notes and action plans. Synchronize the work of cross-functional project teams and provides direct or indirect oversight scope of work.

Evaluate and oversee the development and implementation of Centers for Medicare and Medicaid Services (CMS) and Department of Health Care Services (DHCS) risk adjustment program changes; incorporate changes and requirements into strategy.

Duties Continued

Develop and manage risk adjustment data infrastructure programs and manage deliveries from beginning to end coordinating with internal teams. Ensure program objectives and deliverables are in alignment with department and L.A. Care goals. Develop program initiative timelines, goals and ensures everything is on schedule and within stated budgets.

Serve as a liaison between all I.T. teams to ensure alignment with program goal(s). Develop and manage detailed program t plans, timelines, and deliverables across multiple program activities and risk adjustment initiatives. Provide program coordination with internal risk adjustment functional teams to ensure alignment and progress/completion of program/initiative deliverables. Utilize a client relationship management (CRM) or another system to organize information and facilitate outreach communications, perform forecasting, and measure the performance of programs.

Collaborate with key stakeholders on program implementation and facilitate communications with cross-functional departments on the status of ongoing activities, manage compliance to scope and reporting requirements. Obtain approvals from management.

Partner with key stakeholders to develop communication, test, training, risk management/mitigation plans, and plan of record. Monitor inter-connected programs/project work product, outcome and interplay to be able to make necessary enhancements or modifications as appropriate to ensure alignment with department objectives. Coordinate cross-program/project activities as necessary.

Formulate, organize and coordinate inter-connected programs in encounter and supplemental data collections, system processes, develop and maintain Standards of Operations (SOPs), retrieval and coding vendor platforms workflows, and update regulatory data submissions for risk adjustment data management and methodologies for all three product lines.

Create and manage the Participating Provider Groups (PPGs) related to provider educational webinar presentation decks. Manage PPGs Risk Adjustment meeting agendas, minutes, and deliverables for various risk adjustment programs and initiatives.

Track and identify trends across various risk adjustment programs and initiatives for continuous process improvement opportunities and to set up best practices to coordinate with PPGs to close care gaps. Identify 

issues determined to affect risk adjustment and collaborate with the affected teams to resolve those issues that comply with internal and external governing rules and regulations.

Develop and distribute reports for senior leaders as it relates to risk adjustment metrics and performance. Assess program performance and aim to maximize ROI, utilize change management strategies to implement enhancements and process improvements as necessary.

Navigate and create reports that monitor KPIs. Ensure the accuracy and timeliness of report and data given to key stakeholders. Monitor program operations for quality, efficiency, and effectiveness.

May work with vendors, consultants and government agencies that may include vendor management responsibilities.

Perform other duties assigned.

Education Required

Education Preferred

Experience

Required:

At least 4 years of experience in handling encounter data and/or risk adjustment programs or projects.

At least 4 years of work experience performing problem solving, policy, and/or program implementation.

Experience with Process Improvement Methodology including defining and documenting workflow.

Experience with Workflow Tools - JIRA, Data Lake, Project Server etc.

Technical program experience in large distributed systems, complex competing environments, Micro services Architecture, Cloud computing etc.

Experience resolving effective program critical metrics and using them to measure program success and identify issues.

Experience in program management tools and knowledge of both Agile and Waterfall methodologies and ability to apply them when best suited.

Preferred:

At least 5 years of experience in Health Care and Managed Care.

Experience in finance management.

Skills

Required:

Strong strategic mindset.

Excellent verbal, written communication and presentation skills.

Excellent problem-solving skills with the ability to identify research and make decisions.

Ability to work closely and skillfully with all stakeholders across the organization.

Strong organizational, analytical and truth-seeking mentality skills to juggle many tasks without losing sight of the highest priority or roadmap projects.

Excellent skills in identifying process gaps, measuring progress, efficiency and balancing with process overhead and exceptional at facilitating discussions.

Proven technical capability and an understanding of technical designs, challenges, and risks.

Ability to influence, motivate, and align people across a broad variety of job functions through program management skills. Basic understanding of IT driven technologies and Architectures.

Working knowledge of SQL Server, Visual Studio, Oracle, MS Office, Visio, Project Server & Jira Management.

Ability to articulate and communicate effectively and follow the program management Systems Development Life Cycle (SDLC) lifecycles.

Ability to be an effective, collaborative partner with internal and external stakeholders.

Understanding of encounter and supplemental data collections, system processes, and regulatory data submissions for risk adjustment data management and methodologies for all product lines.

Understanding of end-to-end encounters/claims, supplemental, and risk adjustment data software systems.

Ability to lead cross functional internal teams to execute on complex tasks.

Critical thinking, program planning and implementation skills.

Ability to synthesize and analyze qualitative and/or quantitative data.

Knowledge of health care operations or health care systems.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information