MA Risk Adjustment Supervisor

Triple-S; Guaynabo (PR); On-site; USD 90,000 - 130,000; Full time

Job summary

Triple-S in Puerto Rico seeks a leader for Medicare risk adjustment operations and EDPS data processing to ensure CMS compliance and accurate risk adjustment payments.

You will oversee the Risk Adjustment Operations department, drive strategic initiatives, and coordinate with providers and vendors to optimize data quality and payment accuracy.

Qualifications

• Bachelor’s Degree in Business Administration.
• 3–5 years of experience in Accounting or Finance area, preferably in insurance/health industry.
• Experience with risk adjustment or CMS-regulated processes is a plus.

Responsibilities

• Manage the Medicare risk adjustment operational area and EDPS processes per CMS regulations.
• Provide oversight and leadership to the Risk Adjustment Operations department to align with organizational goals.
• Develop strategies to ensure accuracy of risk adjustment payments and minimize risk.
• Monitor vendor performance and contract execution, and guide performance metrics.

Skills

Financial acumen

Data driven insights

Customer focus

One company mindset

Talent development

Practical tech knowledge

Education

Bachelor's Degree in Business Administration

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Let's build healthier communities together, join now!

Job Summary

Responsible for managing the Medicare operational area of the risk adjustment process and encounter data processing (EDPS) in accordance with CMS regulations. Provides oversight and leadership to the Risk Adjustment Operations department to ensure initiatives are aligned to support the goals and objectives of the organization.

Essential Functions

• Develop and implement strategies to ensure accuracy of risk adjustment payments.
• Align providers with revenue management strategy. In coordination with providers department, establish the plans and activities to ensure compliance.
• Responsible for identifying, managing and implementing strategic initiatives to accurately reflect risk adjustment revenue, and minimize risk.
• Develop resolution and plan for action for identified raps and EDPS discrepancies.
• Monitor and oversight vendor performance and contract. Manages, measures and evaluates vendor performance on an ongoing basis.
• Participates and Assess vendor alternatives. Establish performance metrics for review and evaluation.
• Represent the organization in dealing with vendors for the risk adjustment program.
• Oversee the implementation of data management controls to ensure data quality and integrity, developing tracking, validation and reporting tools.
• Oversee risk adjustment data validation audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and conduct medical record chart reviews to validate diagnoses.
• Perform claims and medical record reviews with focus on accuracy of diagnoses, as needed to respond to particular issues, as part of regulatory audit, or as element of oversight audit.
• Participates in the implementation of tactical plans, follows up on assigned tasks, projects, or objectives to ensure that expectations are met.
• Prepare production reports, statistics and presentations when required.
• Assist in special projects and / or initiatives of the corporation.
• Provide recommendations to achieve the Division’s and Company’s goals.
• Hires, trains, coaches, counsels, motivates and evaluates the performance of direct reports. Establishes disciplinary actions when necessary and promotes employee performance recognition when applicable.
• Responsible for preparing, assigning tasks, monitoring workflow and day-to-day execution and employee activities.

EDUCATION

• Bachelor's Degree in Business Administration

Experience

Bachelor’s Degree in Business Administration with a major in Accounting or Finance with three (3) to five (5) years of experience in an Accounting or Finance area, preferably in insurance and health industry.

LICENSES AND CERTIFICATIONS

• None required

COMPETENCIES

• Financial & Business Acumen
• Data Driven Insights
• Customer Delight
• One Company Mindset
• Develops Talent
• Practical Knowledge in Tech

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.