Risk Adjustment Program Manager

Mass General Brigham Health Plan; Somerville (MA); Remote; USD 80,000 - 110,000; Full time

Job summary

An exciting opportunity awaits at a leading healthcare organization, where you will play a pivotal role in transforming risk adjustment processes. As a Program Manager, you will lead projects that enhance member experiences and ensure compliance with healthcare regulations. This role involves collaborating with diverse teams, analyzing complex data, and presenting insights to executive leadership. Join a forward-thinking company that prioritizes innovation and employee growth while making a significant impact in the healthcare industry. Embrace a supportive environment where your contributions will shape the future of healthcare delivery.

Benefits

Flexible Work Options

Career Growth Opportunities

Competitive Salaries

Comprehensive Benefits Package

Qualifications

• Bachelor's degree required; Master's preferred with 4 years of experience.
• 3-5 years of Risk Adjustment experience; leadership experience preferred.

Responsibilities

• Lead risk-adjusted projects from conception to implementation.
• Manage vendor relationships and negotiate contracts.
• Develop complex analytics for financial performance.

Skills

Risk Adjustment

Project Management

Data Analysis

Leadership

Healthcare Regulations

Medical Coding

Education

Bachelor's Degree

Master's Degree

Job description

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.
The Program Manager leads risk adjustment-related projects from conception to implementation to ongoing operations. The Program Manager will provide thought leadership, project management, vendor management and complex analytic work to ensure the success of the assigned project. The Program Manager will develop new ideas to continually improve the success of the risk adjustment activities within our company.
This role requires interacting and influencing internal and external stakeholders to ensure project success. The Program Manager will follow and document all CMS and MassHealth risk-related activities and ensure the company is positioned to meet any new requirements; as well as develop ideas that enhances our company's competitive position for risk adjustment.
Principal Duties and Responsibilities:
*Lead all internal and external risk-adjusted projects.
*Follows all CMS calls and presentations to ensure compliance and identify new ideas and strategies for improving risk adjustment.
*Manages all vendor relationships and helps negotiate any new or existing contracts.
*Develop and present complex analytics that communicate ongoing financial performance from internally custom-built and externally vendor-built sources.
*Communicate directly with the C Suite as needed for risk adjustment analytics.
*Participate in all audits.
*Develops strategies for provider training, education, and medical management.
*Evaluates data quality of internal and external datasets.
*Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
*Hold self and others accountable to meet commitments.
*Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
*Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
*Other duties as assigned with or without accommodation.

Education

• Bachelor's degree required or the equivalent combination of training and experience, plus four years of related experience; Master's degree preferred

Experience

• At least 3-5 years of Risk Adjustment experience
• At least 1-2 of Leadership experience preferred
• Previous experience leading complex projects and presenting analytics to executive level required.
• Knowledge of HHS Commercial Risk Adjustment and ACA, CMS Risk Adjustment, MassHealth risk adjustment and DxCG required.
• Medical coding certification or equivalent experience preferred.
• Previous experience with CMS risk adjustment audits (RADV) preferred.

Knowledge, Skills and Abilities

• Deep understanding of healthcare regulations and guidelines related to risk adjustment, including but not limited to the CMS-HCC (Centers for Medicare and Medicaid Services Hierarchical Condition Categories) model and other relevant coding and documentation guidelines.
• Ability to analyze data and identify patterns or trends in patient diagnoses, procedures, and documentation that impact risk adjustment scores.
• Skill in working collaboratively with physicians, coders, and other healthcare professionals to improve clinical documentation and ensure accurate representation of patient conditions.
• Ability to analyze complex medical data, identify discrepancies, and make data-driven decisions to improve risk adjustment accuracy and compliance.
• Ability to lead and motivate teams, manage projects, and drive organizational change related to risk adjustment programs.

Working Conditions

• This is a remote role that can be done from most US states
• The role is Monday- Friday with standard business hours in Eastern Time

Physical Requirements

• Standing Occasionally (3-33%)
• Walking Occasionally (3-33%)
• Sitting Constantly (67-100%)
• Lifting Occasionally (3-33%) 20lbs - 35lbs
• Carrying Occasionally (3-33%) 20lbs - 35lbs
• Pushing Rarely (Less than 2%)
• Pulling Rarely (Less than 2%)
• Climbing Rarely (Less than 2%)
• Balancing Occasionally (3-33%)
• Stooping Occasionally (3-33%)
• Kneeling Rarely (Less than 2%)
• Crouching Rarely (Less than 2%)
• Crawling Rarely (Less than 2%)
• Reaching Occasionally (3-33%)
• Gross Manipulation (Handling) Constantly (67-100%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.