Risk Adjustment Compliance, Sr. Principal

Your Role

The Risk Adjustment Compliance team plays a critical role in ensuring that Blue Shield maintains appropriate adherence to federal and state regulations. The Director, Risk Adjustment Compliance will report to the Senior Director, Government Programs Compliance. In this role you will provide strategic leadership and management of the department overseeing compliance with regulations and laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare lines of business, which includes implementation of elements of an effective compliance program. You will oversee the development of risk assessments oversight and the monitoring of work plans pertaining to Risk Adjustment and partner with business areas to ensure and implement effective prevention, detection and correction of compliance issues.

Your Work

In this role, you will:

• Establish and maintain a process for overseeing compliance with regulations and laws related to Risk Adjustment requirements

• Provide guidance to various business departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contractual language

• Conduct compliance reviews and manage a team that conducts compliance reviews, assisting with identification of issues and collaborating with the Risk Adjustment team for remediation of issues

• Perform risk assessments and report emerging trends, deficiencies and variances, report findings to other departments and teams as appropriate

• Set operational priorities including the development and maintenance of effective oversight activities and prioritization of work

• Develop and monitor metrics and other oversight tools that indicate business area compliance. Ensure sufficient monitoring activities to assist with prevention and proactive identification of compliance concerns.

• Provide compliance guidance, direction, and compliance risk assessment to assigned business partners

• Educates, encourages, and assists those within the company to maintain integrity through correction of identified non-compliance in order to meet the requirements of Government-sponsored health care programs

• Participate in mock and actual CMS and other regulatory audits and coordinates with Internal Audit, Regulatory Compliance and/or Market based Regulatory Affairs on responses to agency inquiries and oversees the internal and external processes required to ensure the Company maintains a consistent state of Audit readiness.

• Maintains a current working knowledge of various laws, regulations, and industry guidance that impacts the health industry generally, and government programs in the health sector specifically, including fraud and abuse and anti-kickback statutes, OIG and government health plan guidelines and state marketing compliance laws, prompt pay, provider adequacy and other laws.

• Plan and collaborate with other teams and leaders on complex projects/programs necessitating the origination and application of new and unique approaches. 

• Perform other duties as assigned

Your Knowledge and Experience

• Requires a bachelor’s degree in business administration, Public Policy, Public Health, Health Administration, related field, or equivalent experience required. 

• Master's Degree CPA, CISA, JD, MHA, MBA, MIS or equivalent experience preferred

• Requires 10+ years compliance experience, with increasing responsibility for risk adjustment coding or related compliance functions in a health plan environment, with CMS, DHCS, and state Medicaid/Medi-Cal regulations

• Requires at least 6 years of management experience as a people leader with direct reports.

• Requires proven experience with RADV audits, prospective and retrospective chart reviews, encounter data, claims submissions, OIG investigations, False Act implications, and provider education 

• Requires deep understanding of CMS-HCC, CDPS+Rx, and ACA risk adjustment models

• Requires solid understanding in ICD-10, CPT, and HCC coding 

• Requires familiarity with