Director, Government Programs Risk Adjustment & Audit

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience.  Some of our offerings include:

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

• Annual incentive bonus plan based on company achievement of goals

• Time away from work including paid holidays, paid time off and volunteer time off

• Professional development courses, mentorship opportunities, and tuition reimbursement program

• Paid parental leave and adoption leave with adoption financial assistance

• Employee discount program

Job Description Summary:

​​​The Director, Government Programs Risk Adjustment & Audit assumes overall leadership of the risk adjusted revenue optimization strategy and oversight of Government Programs Risk Adjustment programs.

Job Description

• ​Interface with Blue KC operational and clinical leadership to assist in identification of operational and coding best practices in chronic condition management, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding.   

• ​Interface with external provider partners’ operational and clinical leadership to assist in identification of operational and coding best practices in chronic condition management, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding. 

• ​Provide Government Programs oversight to ensure Medicare Advantage and ACA Risk Adjustment and state regulations are maintained.  

• ​Own the coordination and implementation of retrospective medical record retrieval and review campaigns, prospective provider education programs, regulatory audit activities, and compliance monitoring initiatives designed to ensure accuracy and compliance of reported conditions.

• ​Manage the team accountable for risk adjusted revenue initiatives and works cross-functionally with clinical and technical teams to develop the tools, processes, and reporting required to ensure a compliant risk adjustment program. 

• ​Build and maintain the risk adjustment roadmap which defines the strategic initiatives, operational timelines and regulatory audit and oversight functions to meet risk adjustment regulatory requirements and drive program performance. 

• ​Interpret and monitor state and federal regulatory guidance for risk adjustment, audit and documentation and coding accuracy standards.  

• ​Provide oversight of the documentation and coding educational programs with performance tracking for internal coding operations and provider partners based on analytics and guidance for Risk Adjustment initiatives. 

• ​Develop and deliver educational materials or programs for accurate documentation to support all Government Programs quality care gap closure. 

• ​