Risk Adjustment Consultant

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.

Job Summary

Under the supervision of the Senior Manager of Provider Consulting & Operations, this individual will support the operations and analysis of all risk adjustment programs and serve as the primary point of contact to a select portion of our provider network. This includes strategically important business partners, such as integrated delivery networks, large facilities and/or physician organizations. This individual will also work closely with internal departments and external vendors to ensure that risk adjustment programs are implemented and operated at the highest levels of performance. The Risk Adjustment Consultant will also work closely with our Network Contracting, Clinical and Care Management departments to deliver timely reporting and performance management advisory services to our provider network. This individual regularly demonstrates self-direction and motivation toward completion of on-going department initiatives.

Key Responsibilities/Duties – what you will be doing

Provider Engagement

• Develop and maintain strong and effective working relationships with key business and medical leaders at provider organizations within our network
• Coordinate and facilitate regularly scheduled and ad hoc provider meetings to provide operational updates, discuss strategic initiatives and improvement opportunities
• Work collaboratively with risk adjustment provider educators and the quality assurance team to focus the provider training and education specifically related to coding accuracy and documentation to high impact providers

Data Analysis

• Support the evaluation of medical group opportunities and challenges specific to risk adjustment performance, identify and/or modify training needs and/or programmatic interventions to improve performance and refine the engagement plans
• Analyze, interpret and synthesize medical group specific results and risk score trend information; deliver the results of standard and ad hoc analyses to improve awareness and understanding of risk scores and the quality, accuracy and identification of member health conditions
• Perform high level financial analysis on risk adjustment programs to evaluate and report financial impact to provider organizations

Risk Score Reporting

• Build and refine medical group specific profiles including but not limited to governance, financials, risk scores, resources, and technology
• Manage provider outreach and ongoing communications/reporting for all risk adjustment programs and initiatives. Serve as the risk adjustment subject matter expert to address provider concerns and assist them in understanding the complexities of risk adjustment programs and the resulting data

Collaboration with Internal Stakeholders and External Vendors

• Develop effective and positive working relationships with internal partners (Network Contracting, Clinical Services, Provider Performance Management, Actuarial, etc.) to collaborate on provider engagement and performance improvement initiatives
• Collaborate and coordinate with internal partners to conduct comprehensive analysis and deliver professional presentations to our provider network at shared meetings
• Manage multi-faceted vendor initiatives to ensure smooth implementation and operations
• Support the Risk Adjustment department in efforts to assess additional diagnosis coding opportunities that can be procured or potentially developed internally

Administration

• Attend provider engagement meetings, document provider concerns and key decisions, and manage follow up actions as necessary
• Stay informed about CMS and industry trends and best practices; utilize this knowledge to recommend modifications to Point32Health’s risk adjustment programs and provider engagement practices
• Support the development and refinement of key deliverables to our provider community, including presentations, reference material and communications

Qualifications – what you need to perform the job

QUALIFICATIONS – what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE: 

• Bachelor's degree required, preferably in related field. Graduate degree preferred.

EXPERIENCE (minimum years required):

• Three to five years of experience in a progressively responsible role with stakeholder management experience in a complex operational setting or consulting role. Previous experience working in strategy implementation, analytical and process improvement in the health care / health insurance sector either for a health plan, provider group or management consultancy is a plus. Understanding of US Health Policy and experience working with CMS, health insurers and medical providers highly desired.

SKILL REQUIREMENTS:  

• Highly energetic, organized, detail-oriented, resourceful and self-motivated
• Highly proficient in Microsoft Excel, PowerPoint and Word; additional database systems a plus
• Excellent interpersonal and communication skills
• Ability to work collaboratively with both internal and external resources
• Ability to develop professional and effective relationships as a strategic advisor to our provider network
• Ability to take responsibility, prioritize tasks and follow through to completion
• Ability to organize, manage, and analyze large sets of data

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. 
• May be required to work additional hours beyond standard work schedule.

DISCLAIMER
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification.  They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.  Management retains the discretion to add to or change the duties of the position at any time.
 

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.