Senior Manager, Quality Risk Adjustment Programs

Job Summary:

The Senior Manager, Quality Risk Adjustment Programs is responsible for driving execution of the Quality Risk Adjustment (QRA) programs and managing the development of and adherence to the QRA Compliance Plan across all lines of business for the organization.

Essential Functions:

• This position serves as the source of truth for Risk Adjustment coding guidelines and is accountable for project managing all audits including but not limited to Risk Adjustment Data Validation (RADV)
• Builds and manages Quality Risk Adjustment Team to perform risk adjustment auditing in a virtual environment
• Works with all markets to develop and execute new, scalable, consistent provider education programs including onsite sessions, webinars, developing compliant leave-behinds, and more
• Uses analytics to identify potential risk adjustment compliance risks
• Trends data and prepares corrective action plans to remediate issues and to mitigate future risks
• Develops QRA program dashboards, vendor QA reports, and productivity reporting using KPIs
• Analyzes provider/member data to ensure the Risk Adjustment Factor accurately reflects the membership health profile
• Project manages the Risk Adjustment Department’s policies and procedures processes with input from stakeholders – ensures deadlines are met with necessary revisions
• Develops and implements processes and procedures to ensure the accuracy and completeness of the Medicare Risk Adjustment, Medicaid and ACA/Marketplace data, and to ensure compliance with all CMS and State regulations and guidelines
• Maintains understanding of all CMS and state requirements and directives for Risk Adjustment to ensure process is compliant with these requirements
• Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
• Works closely with CareSource’s Legal and Compliance teams to identify risks and to build strategy to mitigate them including but not limited to managing the QRA team, providing feedback to vendors and providers, and developing a scalable, consistent provider education program
• Requires the use of strong project management skills using Key Performance Indicators (KPIs) to drive operational execution of the QRA Team including tracking and managing productivity of QA work and provider education 
• Responsible for developing, implementing, and managing CareSource’s Quality Risk Adjustment Provider Education program at a market level to help improve risk adjustment accuracy 
• Uses data analytics for identification of provider level risk opportunity, assignment of provider intervention approaches, working closely with market leadership to engage/educate providers
• Perform any other job duties as requested

Education and Experience:

• Bachelor of Science degree in Finance, Business Administration, or Clinical related field or equivalent work experience is required
• Seven (7) years of experience in healthcare, preferably in a managed care organization
• Three (3) years of risk adjustment coding/auditing experience
• Three (3) years of people management, overseeing medical chart coding/auditing teams
• Experience managing complex projects in a virtual and in-person environment

Competencies, Knowledge and Skills:

• Proficient with Microsoft Excel
• Knowledgeable of CDPS-Rx and HHS/CMS Risk Adjustment regulations
• Knowledgeable of ICD-10 and CPT codes
• Knowledge of healthcare reporting standards preferred
• Ability to manage, develop, motivate and reward professional staff
• Ability to effectively report data, analyze facts, and exercise sound business judgment when making recommendations
• Critical listening and thinking skills
• Proficient with Microsoft Suite to include Word, Power Point, Outlook, Visio, and MS Project
• Ability to work independently and to manage multiple priorities with limited resources
• Ability to analyze problems, draw conclusions, develop processes and communicate status and results
• Excellent oral and written communication skills
• Ability to interact with executive levels of management as well as external stakeholders

Licensure and Certification:

• Certified in medical coding:  American Association of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) required
• Project Management Professional (PMP) strongly preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.