AVP, Encounters

Molina Healthcare; Idaho; On-site; USD 122,000 - 239,000; Full time

Job summary

A leading healthcare organization is looking for an AVP, Risk Adjustment Encounters to lead strategy and governance for compliance and encounter processes. The role involves ensuring accurate submission of encounter data, managing operational efficiencies, and collaborating across departments. Candidates should have extensive healthcare experience and strong leadership skills. This position offers a competitive salary and benefits package.

Qualifications

• 8+ years of healthcare or operational experience in related roles.
• Minimum 2 years in a Director level role or above.
• Extensive understanding of Medicare Advantage, ACA, and Medicaid processes.

Responsibilities

• Ensure encounters accuracy for assigned lines of business.
• Increase volume of encounters from providers.
• Manage encounter submissions and rejection management.

Skills

Healthcare operational experience

Influential communication

Vendor management

Education

Bachelor's Degree or equivalent experience

Job description

Overview

AVP, Risk Adjustment Encounters role overview and responsibilities at Molina Healthcare.

The AVP, Risk Adjustment Encounters is responsible for establishing enterprise-wide strategy, governance, and oversight of processes that track, evaluate, and submit encounter deletions for Medicare Advantage, ACA, and Medicaid lines of business. This role has decision-making accountability for ensuring compliance with complex regulatory requirements, protecting the integrity of enterprise revenue, and enabling the organization’s overall risk adjustment strategy.

Responsibilities

• Ensure encounters accuracy and completeness for assigned lines of business (Encounter Production, Audit, Production Vendor Oversight).
• Increase volume of encounters received from providers and improve completeness of encounter data with states, CMS, and HHS to reconcile data.
• Manage encounter submissions, rejection management, and resolution for all lines of business and provide leadership support in managing overall healthcare costs.
• Influence across multiple organizational functions — Payment Integrity, Claims, Encounters, Finance, and Actuarial.
• Design and implement efficient enterprise-wide processes and governance structures spanning claims, encounters, clinical, finance, and actuarial functions.
• Identify, develop, and train staff; standardize end-to-end processing and accuracy of encounters; work with partner departments to improve processes affecting quality and timeliness.
• Monitor and manage resolution for potential penalties related to accuracy and timeliness of encounters submissions.
• Lead projects/initiatives to reduce administrative costs and ensure accurate encounters, impacting Risk Revenue and Quality Compliance; align with VP Encounter on goals and cost-saving opportunities; convene work groups and measure success.
• Partner with VP Encounter to participate in Corporate Operational Leadership Team to analyze root causes of variations, propose performance improvements, identify risks, and lead changes in encounters processes.
• Collaborate with leadership and partners to establish improvement objectives and execute priorities aligned with strategic goals.
• Manage Molina staff and oversee vendors to achieve efficient, compliant service levels and high quality across lines of business.
• Ensure state, federal, Molina regulations, Policies/Procedures, and SOPs are implemented and followed to maintain high compliance within the Encounters Department.
• Assist VP Encounter in managing costs to meet/exceed budgets and seek opportunities to improve productivity and automation to reduce unit costs and G&A.
• Identify and implement systematic approaches to improve first pass rate, increase operational efficiency, and enhance effectiveness.

Knowledge/Skills/Abilities

• 8+ years of healthcare or operational experience in related roles.
• Minimum 2 years in a Director level role or above.
• Extensive understanding of Medicare Advantage, ACA, and Medicaid risk adjustment processes, including encounter data submission and deletion requirements.
• Accountability for multiple markets or product lines.
• Experience managing department budgets within prescribed parameters.
• Experience with account management and vendor management.
• Excellent verbal and written communication skills.
• Ability to influence and drive change among peers and others within the Molina organization.
• Ability to envision and craft proposals, obtain consensus, and implement future state processes and systems to support strategic direction.

Job Qualifications

REQUIRED EDUCATION:
Bachelor's Degree or equivalent experience

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $122,430.44 - $238,739.35 / ANNUAL