Senior Director, Risk Adjustment, Encounter Reporting and Analytics

Job Summary

The Senior Director, Risk Adjustment, Encounter Reporting and Analytics (Senior Director,  RA-ERA) is a strategic, analytical, critically thinking senior leader in the Finance organization that is charged with overseeing and leading the risk adjustment, encounter reporting and analytics functions at L.A. Care (LAC) focusing on Medi-Cal, Medicare and Covered CA. 

The Senior Director, RA-ERA will ensure accurate and compliant encounter reporting and risk adjustment and will lead and support the Medicare risk adjustment data validation audit performed by Centers for Medicare and Medicaid Services (CMS). 

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

Duties

Develop,  implement and manage a comprehensive risk adjustment and encounter reporting and analytics  strategy.

Identify opportunities to enhance risk adjustment processes and ensure accurate documentation and coding. Ensure that all risk adjustment and encounter reporting processes comply with Department of Health Care Services (DHCS) and CMS requirements.

Develop and support risk adjustment compliance initiatives. Responsible for support in the Medicare Advantage Risk Adjustment Data Validation audit performed by CMS.

Collaborate with cross-functional teams to drive risk adjustment data validation improvement initiatives including complete provider claims/encounter data, accurate coding, encounter data gaps and their remediation.

Analyze encounter data to identify  gaps and opportunities for improvement and work with internal and external stakeholders to remediate the gaps to improve accuracy and completeness.  Ensure the accuracy, timeliness and completeness of encounter data.

Collaborate with key stakeholders, including providers, vendors, regulators and internal LAC departments to ensure effective data sharing and exchange for accurate encounter reporting.

Monitor the effectiveness of risk adjustment and encounter analytics through the establishment of key performance indicators (KPIs).

Provide leadership, guidance and mentorship to the risk adjustment and encounter reporting and analytics teams.

Duties Continued

Stay current with relevant laws, regulations and policies related to risk adjustment and encounter submissions to CMS and/or DHCS. Ensure that all risk adjustment and encounter reporting activities comply with regulatory requirements and follow industry best practices.

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.

Perform other duties as assigned. 

Education Required

Education Preferred

Experience

Required:
At least 10 years of experience in health care operations, risk adjustment, and/or encounter reporting.

At least 8 years of demonstrated leadership and management experience in a healthcare setting. 

At least 7 years of experience working in Medicare Advantage, Medi-Cal and/or Dual-Eligible
 

Skills

Required:
Comprehensive knowledge of Medicare, Medi-Cal or Covered CA programs including claims, encounters and risk adjustment methodologies.

Strong interpersonal and customer service skills.

Excellent verbal and written communication and presentation skills to convey complex technical concepts to all stakeholder.

Proficiency in data analysis tools and software such as SAS, R, Python or SQL, to extract and manipulate healthcare data for analytic purposes.

Familiarity with ICD-10, CPT coding, and Hierarchical Condition Category (HCC) coding systems

Excellent verbal and written communication skills,

Strong presentation skills.

Proficient in Microsoft Office. 

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information