Overview

The Director, Medicare Risk Adjustment (MRA) will lead the execution strategy and implementation of the organization’s Risk Adjustment Programs to optimize the programs’ clinical benefit, financial accuracy and ensure program compliance with governing bodies’ regulations, including the Center for Medicare and Medicaid Services. This role will partner with leadership to facilitate decision-making based on strategic and tactical recommendations for program improvements. This position will report to the Group President of Operations.

This position requires you to be on site at our HQ in Mclean, VA.

Responsibilities

• Accountable for the MRA program including all aspects of the various methods of executing on an MRA strategy (e.g. prospective, retrospective, concurrent approaches).

• Lead risk adjustment operational programs aimed at monitoring, oversight, and compliance for risk score accuracy.

• Responsible for the program to meet full compliance with state, federal and partner requirements.

• Drives industry best practices and performance results focusing on driving key KPI’s (# visits, RAF score, coding accuracy).

• Manage a coordinated, cross functional and integrated process across the organization to implement programs and streamline activities.

• Develop program goals and key performance indicators (KPIs) to ensure accountability across the organization.

• Partner with Finance and Analytics team to establish risk adjustment analytics such as predictive modeling for coding improvement opportunities, provider coding improvement opportunities, provider coding accuracy, risk score trending and tracking, and transfer payment accruals.

• Partner with cross functional team and external vendors to execute MRA strategy.

• Coordinate with the provider Network Management and the Quality Program to implement tactics for risk adjustment optimization, particularly for provider and member engagement activities.

• Manage processes needed to conduct at home wellness visits.

• Ensure accurate coding for documentation and auditing.

• Collaborate with payer partners and manage key vendor relationships and perform oversight of vendors for performance management and service level adherence.

• Ensure processes and tools required for best-in-class accurate recapture rate.

• Assist provider engagement and operations teams to maximize efficiency of provider conducted MRA visits.

• Oversee and manage the compliance and performance of vendors or third-party administrators performing risk adjustment activities.

• Drive effective auditing documentation practices.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Qualifications

Required Education and Experience:

• Bachelor’s degree in business in business, healthcare administration, or related field.

• 8+ years of successfully leading and executing a comprehensive MA MRA program at scale.

• Minimum 5 years of healthcare experience with knowledge of health plan operations i.e. Claim processing, customer service, enrollment etc.

• Proven experience with commercial and/ or Medicare Advantage risk adjustment functions.

• Proven track record of working collaboratively with clinical and operational colleagues across the organization.

Knowledge, Skills, and Abilities:

• Ability to communicate effectively and sensitively with clinicians and care teams in stressful situations.

• Ability to lead by influence to engage colleagues and lead teams cross-functionally.

• Experience in fostering networks with internal and external stakeholders.

• Possess strong business acumen, excellent strategic thinking, and effective problem-solving skills.

• Excellent verbal and written communications skills with demonstrated ability to communicate, present, and influence both credibly and effectively at all levels of an organization, including executive and C-level.

• Ability to work in a rapidly changing, matrixed environment.

• Proven ability to independently lead complex projects requiring cross functional alignment.

• Ability to be highly organized and systematic.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely-held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.