Risk Adjustment Business Operations Director (Hybrid)

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 141,000 - 261,000; Full time

Job summary

CareFirst BlueCross BlueShield is seeking a Risk Adjustment Business Operations Director to lead risk adjustment outcomes for Medicare Advantage, Medicaid, and ACA markets. The role drives strategic direction, establishes key functions, and oversees enterprise RADV programs across populations and products.

Collaboration with enterprise stakeholders is essential to improve accuracy and performance. The position requires extensive healthcare experience with risk adjustment, strong leadership, and

Qualifications

• Bachelor's degree in a health or analytics field, or equivalent experience.
• 8 years progressive healthcare experience, with 3 years in risk adjustment.
• Experience in Medicaid/Medicare/ACA/BHP environments.
• Coding certification (CPC/CRC/CPMA or CCS/CCS-P) preferred.

Responsibilities

• Define and establish standards for in-year Risk Adjustments, KPIs, OKRs, ROI and risks.
• Oversee enterprise risk adjustment processes and regulatory changes.
• Develop action plans for accurate RADV, encounter data and ACA EDGE submissions.
• Lead partnerships and mentor teams to drive cross-functional improvements.
• Guide executives and stakeholders on regulatory compliance and performance.

Skills

Leadership

Risk Adjustment

Data Analytics

Regulatory Knowledge

Strategic Planning

Education

Bachelor’s Degree

Job description

PURPOSE

The Risk Adjustment Business Operations Director oversees the outcomes and business operations of risk adjustment for Medicare Advantage, Medicaid, ACA/BHP markets. The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key functions, overseeing enterprise risk adjustment performance while identifying areas of improvements and implementing in year programs. In addition, the Director evaluates, modifies, maintains & executes the provider facing Risk Adjustment/Risk Adjustment Data Validation (RADV) programs & actions across all the assigned populations and products. This role collaborates and partners with Risk Adjustment Operations Team and enterprise stakeholders across to manage performance and programs to improve accuracy.

Resp & Qualifications

PURPOSE: The Risk Adjustment Business Operations Director oversees the outcomes and business operations of risk adjustment for Medicare Advantage, Medicaid, ACA/BHP markets. The Risk Adjustment Director is responsible for strategic direction, leadership, establishing and maturing key functions, overseeing enterprise risk adjustment performance while identifying areas of improvements and implementing in year programs. In addition, the Director evaluates, modifies, maintains & executes the provider facing Risk Adjustment/Risk Adjustment Data Validation (RADV) programs & actions across all the assigned populations and products. This role collaborates and partners with Risk Adjustment Operations Team and enterprise stakeholders across to manage performance and programs to improve accuracy.

Essential Functions

• Define and establish standards and frameworks for in year Risk Adjustments related to KPIs, OKRs, ROI, action plans, progress and risks. Establish programs for key data elements to meet industry standards and assess risks adjustments across all relevant risk domains. Develop and manage tracking tools, dashboards, and metrics for monitoring the progress of the Risk Adjustment Program across all lines of business. Drives member and provider interventions closely to ensure comprehensive quality of care that includes preventive medicine screenings and the ongoing assessment and evaluation of chronic conditions. Support the development and delivery of enterprise and market wide training and awareness materials that educate associates and leadership on best practices, pervasive operational risk adjustment issues, risk adjustment tools and processes, and lessons learned.
• Oversee the enterprise risk adjustment process, including impact analysis and actions related to risk adjustment-related regulatory changes. Drive to implement appropriate changes necessary across CareFirst teams and processes to impact business outcomes through development of action plans. Collaborate across the eco-system such as CMS, State, District & BCBSA to drive necessary regulatory improvements. Ensure that risk adjustment activities and decisions are aligned with strategic goals and objectives, and are executed in consideration of the impact on the organizations goals.
• Establish standards for in year programs and provide advisory support in the completion of Risk Adjustment processes, as well as govern, support, and mentor associates within the prospective & retrospective strategies to ensure accurate and complete RADV mitigation, encounter & ACA EDGE submissions. Develop and implement action plans related to accurate and complete prospective, retrospective, and regulatory data submissions affecting assigned products and plans, including detailed work plans, issue logs, and progress reports at the Plan, Provider, LOB, member level. Serve as an SME to guide CareFirsts VPs of Enterprise Quality, Stars & Risk Adjustment & Network along with Actuarial and P/L owners for each line of business, regulatory filings, and financial performance planning & reporting.
• Forge and maintain strategic partnerships across the enterprise to identify risks, improve control effectiveness, and drive cross-functional process improvements that support organizational objectives. Lead, mentor, and develop teams, vendors, and project resources by establishing performance expectations, monitoring goals and milestones, implementing corrective actions as needed, and ensuring alignment with Risk Adjustment strategy, business goals, and organizational priorities

Supervisory Responsibility

This position manages people - 1-5 5-10

Qualifications

Education Level: Bachelor's Degree in Health Care Administration, Public & Population Health, Finance, Business Analytics, or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience

• 8 years of progressive responsibility in healthcare.
• 3 years specifically in risk adjustment environment, within healthcare insurance within Government Programs (MA & Medicaid) & ACA.

Preferred Qualifications

• Masters in Business Administration, Masters in Health Administration or Masters in Public or Population health or a related field.
• Extensive experience leading Risk programs for Medicaid, Medicare Advantage, and ACA/BHP populations, including RADV, encounter data, and ACA EDGE submissions.
• Deep knowledge of CMS regulations, HCC coding methodologies, risk adjustment operations, provider engagement strategies, and healthcare regulatory requirements.
• Proven ability to drive enterprise-wide performance improvement through analytics, KPI/OKR development, program governance, regulatory compliance, and cross-functional stakeholder collaboration.
• Demonstrated success leading high-performing teams and strategic initiatives while partnering with executive leadership, actuarial, quality, network, finance, and operational departments to achieve organizational and financial objectives.

Knowledge, Skills And Abilities (KSAs)

• Knowledge and experience across all regulatory guidelines on Risk Adjustment.
• Experience successfully planning and leading presentations to physicians, internal stakeholders, and C-suite with a focus on coding data and analytics.
• Experienced with effective physician/provider collaborative training to support workflow adjustments to improve clinical coding quality.
• Successful completion of a Coding Certificate program from an accredited organization (i.e., CPC, CRC, CPMA from AAPC, or CCS, CCS-P from AHIMA).
• Strong leadership skills, Risk Adjustment financial acumen, vendor oversight skills & an experience in payer, provider & industry collaboration.
• Ability to work in a fast-paced environment and drive consistent actions across a matrixed environment.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $140,640 - $261,063

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship