Risk Adjustment Program Manager

Location: Marquette,Michigan,United States

POSITION:  Risk Adjustment Program Manager

DEPARTMENT:  Finance

POSITION SUMMARY: 

The Risk Adjustment Program Manager is responsible for leading, implementing, and optimizing UPHP’s managed care risk adjustment program. This role ensures accurate and compliance risk score capture to support appropriate revenue and quality performance in all lines of business. The manager oversees staff, vendor relationships, data analytics, coding accuracy, and cross-functional collaboration to develop and implement comprehensive strategies to manage and drive risk adjustment performance and compliance. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information. 2. Develops and executes a comprehensive Medicare and Medicaid risk adjustment strategy that aligns with regulatory and business goals; creates work plans and timelines for risk adjustment initiatives to achieve UPHP’s program goals.  3. Supervises and manages the day-to-day responsibilities of risk adjustment department team members; responsible for scheduling of time off, coordinating new employee orientation, and conducting 90-day and annual performance appraisals in compliance with UPHP employee policies.  4. Ensures compliance with CMS and state risk adjustment regulations, including appropriate use of HCCs, data submission standards, and audit readiness. 5. Leads risk adjustment workgroups and deliverables. Coordinates cross-functional collaboration with Clinical and Compliance departments to integrate risk adjustment efforts with broader population health strategies.  6. Tracks overall portfolio of risk adjustment projects/initiatives. In collaboration with the accounting department, develops and measures return on investment (ROI) on risk adjustment initiatives, including coding interventions, vendor engagements, and member and provider outreach strategies.   7. Oversees the analysis of risk scores, claims, encounters and supplemental data to identify opportunities for improved coding and accuracy.  Supports root cause analyses and develops targeted interventions designed to improve risk adjustment scores and initiative outcomes. 8. Develops and oversee delivery of risk adjustment training program to educate the provider network of best practices for coding and risk adjustment activities. 9. Manages relationships with external risk adjustment vendors, including monitoring and evaluating vendor performance.  10. Develops and recommends annual operating budget and controls expenditures within approved budget objectives. 11. Maintains confidentiality of client data. 12. Performs other related duties as assigned or requested. 

POSITION QUALIFICATIONS:

Education:

Minimum:

Bachelor’s degree in a health care administration, business, or related field; five (5) years of relevant experience in lieu of a degree will be considered.  

Preferred:

Master’s degree in health care administration, business, or related field; healthcare coding certification through AAPC or AHIMA 

Experience:

Minimum:

Three (3) years in health care risk adjustment, clinical quality operations, claims coding, compliance, or other relevant healthcare operations experience; one (1) year supervisory or project management experience required. 

Preferred:

Three (3) years of experience in risk adjustment operations in a Medicare or Medicaid managed care organization or health plan; three (3) years supervisory experience. 

Required Skills:

Proficiency in Microsoft OfficeExcellent problem solving, negotiation, and conflict resolution skillsExcellent human relation and oral/written communicationExcellent organizational and prioritization abilities 

Desired Skills:

Proficiency in Medicare risk adjustmentKnowledge of MS PowerPoint Knowledge of state Medicaid guidelines and CMS regulationsKnowledge of Medicaid reimbursement models, managed care contracts and regulatory requirements Understanding of quality improvement programs The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.

 

Physical Requirements:

[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]: Ability to enter and access information from a computerAbility to acces