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Risk Adjustment Team Lead

Company: PacificSource
Location: Bend
Posted on: April 8, 2021

Job Description:

Looking for a way to make an impact and help people?Join PacificSource and help our members access quality, affordable care!PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.Position Overview: Risk Adjustment Team Lead is responsible to lead the data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable population. Ensures compliance to all applicable laws, guidance, and regulations. This role will interface with providers, vendors, and clinical leadership to support programs that provide measurable, actionable solutions resulting in improved accuracy of medical record documentation and coding. Collaborate with internal teams such as Finance, Actuarial, Provider Network, IT, Operations, and Quality to streamline and leverage opportunities to jointly develop and implement optimization strategies. Responsible for leading and developing team of Risk Adjustment Analysts.Essential Responsibilities: Coordinate business activities by maintaining collaborative partnerships with key departments.Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.Actively participate as a key team member in department meetings.Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.Propose and assist Leadership in implementing analytic strategies and solutions that challenge and enhance current operations.Lead process improvements that will optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden.Responsible for overseeing regular reporting and development of new reports to help ensure company goals are met.Responsible for facilitating internal meetings to identify and rectify various data submission and adjudication errors related to risk adjustment data submission.Stay up to date with current CMS regulations and announcements affecting risk adjustment. This includes review of regulatory announcements, attending educational sessions provided by regulatory entities, as well as staying apprised of educational opportunities within the industry.Demonstrate expertise in running all applicable risk models including the various CMS models for Medicare Advantage members, the HHS model for Commercial ACA members, and others as needed.Lead the risk adjustment analyst team to maintain data sets leveraging internal data, response data from regulatory entities (EDGE files, MMR, MOR, RAPS Response, MAO-004, etc.), and ancillary data sources to be consumed across the enterprise.Responsible for oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy.Lead team in performing root cause analysis to maintain high integrity data and processes to minimize discrepancies and gaps.Develop, maintain, and report out on actionable metrics related to risk adjustment and incorporating quality/health outcome metrics where applicable.Assist with projecting annual receivable amounts, preparing projections related to pricing efforts, and predicting cost utilization as it relates to risk adjustment.Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes. Work with changing data, file specifications, and internally coordinate releases and modifications through approved procedures.Supporting Responsibilities: Meet department and company performance and attendance expectations.Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.Perform other duties as assigned.Work Experience: Six years' experience in data analytics required, to include at least three years' experience in Health Plan required. In depth Medicare and Commercial ACA risk adjustment experience required, including risk model and CMS guidelines, RAPS/EDS & EDGE data submissions, retrospective and prospective programs, and RADV audits. Familiarity with Medicaid risk adjustment required. Expertise in Microsoft Excel and SAS/SQL is required. Experience in leading projects and project teams required. Familiarity with Risk Adjustment Documentation and Coding practices preferred. Medicare Stars and/or HEDIS experience preferred. Supervisory experience preferred.Education, Certificates, Licenses: Bachelor's degree in Mathematics, Statistics, or similar research related field required. Advanced degrees preferred.Knowledge: Effective team leader and builder including ability to establish accountability within the team. Excellent analytical and problem solving abilities are required. Mastery of theories and applications of computer programming required (SAS, SQL, and VBA are the primary tools used). Ability to keep current with changing technologies, work independently under limited supervision, exercise initiative within established procedural guidelines, and prioritize work to meet established deadlines a must. Ability to communicate clearly and concisely, both orally and in writing when making presentations and creating documents. The ability to establish and maintain effective work relationships, exercise good judgement, and demonstrate decisiveness and creativity. Read, understand, and interpret documents of complex subject matter.Competencies Building TrustBuilding a Successful TeamAligning Performance for SuccessBuilding Customer LoyaltyBuilding Strategic Work RelationshipsContinuous ImprovementDecision MakingFacilitating ChangeLeveraging DiversityDriving for ResultsEnvironment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5%of the time.Our ValuesWe are committed to doing the right thing.We are one team working toward a common goal.We are each responsible for customer service.We practice open communication at all levels of the company to foster individual, team and company growth.We actively participate in efforts to improve our many communities-internally and externally.We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.We encourage creativity, innovation, and the pursuit of excellence.Physical Requirements:Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer:This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

Keywords: PacificSource, Bend , Risk Adjustment Team Lead, Accounting, Auditing , Bend, Oregon

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