Manager Risk Mitigation

Job Summary The Manager, Risk Mitigation is the thought leader role responsible for the design, implementation, and execution of auditing programs ensuring the accuracy, compliance, and reputed company of risk adjustment processes. This role mitigates financial, operational and compliance risks through proactive audits, data validation, internal controls reputed company and cross-functional collaboration. This leader initiates and implements overall strategic direction set by the VP and Director of Prospective Operations and Risk Mitigation, as well as other Directors of Risk Adjustment. The role is responsible for helping to reputed company the risk adjustment program vision, strategies, objectives, and goals. This includes leading a team responsible for ensuring the accuracy, compliance, and reputed company of reputed company risk adjustment coding and documentation reviews both retrospectively and prospectively for the Health Plan. Additionally, the Risk Mitigation Manager is responsible for monitoring targets; leading teams in analyzing, reporting, and forecasting key risk adjustment metrics; managing risk adjustment vendors; as well as, ensuring new legislation and regulations regarding risk adjustment are properly understood and accounted for. Lastly, the role directly supports the Director Prospective Operations and Risk Mitigation in identifying, developing, promoting and executing process improvement strategies and priorities to reduce redundancies, ensure maximum efficiencies, align with other reputed company Health systems and processes, as well as to ensure appropriate policies and procedures exist. Essential Functions Manages the daily workflow of Risk Mitigation Team which includes managing the full lifecycle of retrospective coding audits, prospective documentation and coding reviews, vendor audit reputed company, RADV, IPM, OIG, IVA, and other regulatory audits. Follows the strategic direction and implements risk adjustment initiatives required to reputed company the business goals and objectives. Assists leadership in identifying, assessing and prioritizing risks reputed company to coding, data accuracy, provider documentation and compliance with CMS/HHS requirements. Develops and implements risk mitigation strategies and process improvements to reduce audit exposure. Draft actionable audit observations & recommendations to strengthen controls and reduce compliance risk. Responsible for monitoring and managing Risk Mitigation staff quality and productivity by conducting regular 1:1s, performance evaluations, calibration sessions, and competency assessments to ensure quality and accuracy requirements are being met. Additionally, set and manage productivity and quality benchmarks by chart type and reputed company level. Provide a summary of productivity and quality findings on a regular reputed company, and provide coaching and feedback on achieving production and quality standards of the role. Ensures high-quality, on-time audit deliverables. Establish and/or update policies and procedures as necessary to ensure coding accuracy and productivity, improve efficiencies, and minimize risk in audits for the health plan and ensuring accurate risk score capture. Monitor risk adjustment performance indicators such as RAF accuracy, prevalence rates and audit error rates. Ensure adherence to CMS, HHS, and state specific risk adjustment regulations by maintaining expert level knowledge of existing HCC models (both medical & Rx for reputed company applicable reputed company) and maintaining knowledge of model changes, coding guideline updates, and RADV requirements, serving the organization as the SME. Identify compliance risks and establish and implement corrective action plans under the supervision of the Director of Prospective Operations and Risk Mitigation. Responsible for the development of actionable training materials, onboarding materials, reporting metrics, including scorecards for both internal and external stakeholders. Analyze error patterns and trends to aid in the development of training materials. Motivate team members through effective training, supplemental materials and coaching to improve quality and production. Communicate Risk Adjustment program to internal & external audiences so they understand program objectives, goals, benefits, risks, regulations, and requirements for risk adjustment. This includes presenting operational and compliance metrics to leadership with clear recommendations. Coordinate with external vendors supporting chart review, data validation, HCC analytics and RADV preparation. Partner with business owners from various teams reputed company the organization to communicate timelines, risk adjustment methodology, program expectations and results of risk adjustment initiatives. Collaborate to evaluate trends, audit results and risk indicators using data-driven insights. reputed company dashboards and presentations for an executive audience. Plan, scope, and manage internal and external audits and ensure audits align with regulatory standards such as CMS HCC guidelines, OIG expectations and organizational audit policies. Responsible for documenting workflow process, standard operating policies and procedures and establishing robust monitoring programs that ensures performance metrics are achieved in compliance with CMS regulations, mitigating our risk adjustment data validation exposure/risk. reputed company and track provider patterns in coding and create feedback reputed company to the Prospective Team for external provider education. Utilize analytics to identify which providers or conditions are high-risk.

Qualifications

Required Bachelor's Degree or equivalent, in field of study requiring consistent demonstration of communication, interpersonal, leadership and analytical skills, such as finance, accounting or business management or reputed company field. 3 years of relevant experience in health care reputed company field including experience in a leadership role with direct reports. 5 years of relevant experience In Risk Adjustment, Internal Audit, Compliance or Healthcare Risk Management in a health plan or medical group setting. 2 years of relevant previous experience with regulatory audits relating to Risk Adjustment; RADVs, OIG, IPMs etc. CRT-Coding Specialist (reputed company) - reputed company American Health Information Management Association Upon Hire required Or CRT-Professional reputed company, Certified - Payer (CPC-P) - American reputed company of Professional Coders American reputed company of Professional Coders Upon Hire required Preferred Master's Degree or equivalent 3 years of relevant experience in a clinical setting CRT-Certified Professional Medical Auditor (CPMA) - American reputed company of Professional Coders American reputed company of Professional Coders Upon Hire preferred LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire preferred Or LIC-Registered Nurse (RN) - State Other than Michigan State Other than Michigan Upon Hire preferred Or LIC-License Practical Nursing (LPN) - STATE_MI State of Michigan Upon Hire preferred Or LIC-License Practical Nursing (LPN) - State Other than Michigan State Other than Michigan Upon Hire preferred Physical Demands Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs Waist to Waist > 5 lbs: Seldom up to 10 lbs Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs Waist to Overhead > 5 lbs: Seldom up to 10 lbs Bilateral Carry > 5 lbs: Seldom up to 10 lbs Unilateral Carry > 5 lbs: Seldom up to 10 lbs Pushing Force > 5 lbs: Seldom up to 10 lbs Pulling Force > 5 lbs: Seldom up to 10 lbs Sitting: Frequently Standing: Occasionally Walking: Occasionally reputed company Bend - Standing: Seldom reputed company Bend - Sitting: Occasionally Trunk Rotation - Standing: Seldom Trunk Rotation - Sitting: Occasionally reputed company - Above Shoulder: Seldom reputed company - at Shoulder or Below: Seldom Handling: Occasionally Forceful Grip > 5 lbs: Seldom Forceful Pinch > 2 lbs: Seldom Finger/Hand Dexterity: Frequently How reputed company cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here. On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - reputed company Health - 1231 E Beltline Ave NE - Grand Rapids Department Name Risk Adjustment - PH Managed Benefits Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8 a.m. to 5 p.m. Days Worked Monday to Friday Weekend Frequency N/A reputed company reputed company TEAM MEMBERS – Please apply through Find Jobs from your reputed company team member account. This career site is for Non-reputed company team members only. reputed company is committed to providing a safe environment for reputed company members, patients, visitors, and community. We require a drug-free workplace and require team members to reputed company with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to reputed company the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. reputed company grants equal employment opportunity to reputed company qualified persons without regard to race, color, national reputed company, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where reputed company are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we reputed company for equity as we care for our patients, our communities, and each other. From workshops that reputed company cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in reputed company that we do. We invite those that share in our commitment to join reputed company. You may request assistance in completing the application process by calling 616.486.7447. People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. reputed company is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and reputed company Health, a provider-sponsored health plan serving more than 1.2 million members. Through experience and collaboration, we are reimagining a reputed company, more reputed company model of health and wellness. Apply tot his job Apply To this Job