Risk Adjustment Program Manager

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

We are looking for a professional with experience in Risk Adjustment for the Medicare, Medicaid and Qualified Health Plan ("Exchange") populations. As a Risk Adjustment Program Manager, you will develop strategies to ensure risk adjustment data accuracy, coordinate the work of internal and external partners, and respond to new requirements from CMS or company leadership. You will supervise the work of analysts and specialists to reconcile encounter submissions, prepare ongoing reporting and analyze the success of past projects.

This role is ideal for anyone with experience in Risk Adjustment ready to take the next step in their career at a leading not-for-profit health insurer focused on improving the health of all New Yorkers.

• Ensure high-quality encounter submissions: Use CMS response files, vendor reports, and internal claims data to determine the source of submission or adjudication errors.
• Work with key stakeholders to resolve issues and resubmit files.
• Identify and close risk score gaps: Continually monitor member- and provider-facing activities to identify data inaccuracies or care gaps.
• Work with vendor and provider partners to resolve issues and improve outcomes.
• Use data to refine Risk Adjustment strategy: Assess our Risk Adjustment program by reviewing year-over-year risk condition persistence and the impact of supplemental activities. Modify and refine Risk Adjustment strategy based on your findings.
• Serve as Subject Matter Expert: Work collaboratively with other departments to ensure Risk Adjustment goals are integrated into MetroPlusHealth operations. Educate departments across the organization about how their activities impact risk adjustment.
• Prepare ongoing reporting: Supervise analysts and utilize our Data Warehouse to conduct in-depth analysis of critical issues, including claims, enrollment and provider coding trends.
• Work proactively with vendors: Monitor and guide external vendor partners to ensure program goals are being met.
• Ensure regulatory compliance: Continually review CMS or state guidance and regulations around Risk Adjustment, encounter submission and related topics. Update internal processes to ensure strict adherence to regulatory guidelines.
• Lead Request for Proposal (RFP) process and manage new vendor implementations.
• Supervise and provide feedback to analysts and specialists.

• Bachelor's degree required; Master's strongly preferred.
• At least 8 years experience working in health care, including at least 5 years working in Risk Adjustment at a Health Insurer, Provider Group or Risk Adjustment vendor.
• Supervisory experience in an analytics or healthcare setting.
• Thorough understanding of Medicare, Medicaid and commercial insurance markets and Risk Adjustment models, including at least two of the following models: HHS-HCC (Qualified Health Plans), 3M CRG (New York State Medicaid), CMS-HCC (Medicare).
• Experience modeling member-level risk score impacts of various activities.
• Strong analytical skills, including using SQL or other programming language to query large relational databases.
• Proactive communication style and ability to work with a variety of stakeholders to achieve project goals.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications

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