Sr Mgr - ACA Risk Adjustment Operations & Analytics (hybrid)

PURPOSE OF THE JOB

• This position reports into the General Manager of the Individual Segment and is responsible for the oversight and execution of all aspects of the ACA Risk Adjustment programs within the organization, with the purpose of improving the overall risk adjustment performance of our ACA Individual and Small Group Commercial populations.
• In support of this purpose, this position will perform activities including but not limited to: Develop and execute on business strategy; Execute technical data extraction and submission to CMS and other vendor partners; Execute risk gap closure programs, including medical record retrieval and analytic targeting models; Interface with Finance and Actuarial on risk adjustment financial plans and accruals; Maintain effective working and oversight relationship with downstream vendors and internal stakeholders; Execute risk adjustment data validation audit requirements; and Ensure compliance with all CMS requirements and regulations.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

• 5 years of experience working for a healthcare organization / health insurer, including managed care
• 5 years of progressive experience in risk adjustment program leadership with a track record of successful metrics
• 5 years of experience with actuarial, finance, and/or healthcare economics teams in PLRS/RAF calculations, projections, and financial / pricing impact analyses for initial, mid-year and final CMS risk transfer reports
• 3 years of experience managing end-to-end CMS risk adjustment submission process with internal staff, vendor, or combination

• Bachelor of Arts or Bachelor of Science degree

• N/A

• N/A

PREFERRED QUALIFICATIONS

• 7 years of experience working for a healthcare organization / health insurer, including managed care
• 7 years of progressive experience in risk adjustment program leadership with a track record of successful metrics
• 7 years of experience with actuarial, finance, and/or healthcare economics teams in PLRS/RAF calculations, projections, and financial / pricing impact analyses for initial, mid-year and final CMS risk transfer reports
• 5 years of experience managing end-to-end CMS risk adjustment submission process with internal staff, vendor, or combination
• 3 years of management or supervisory experience

• Master’s degree in business, mathematics, statistics, or related field of study.

• N/A

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Evaluate, design, and implement risk capture and improvement programs with the goal of receiving and capturing appropriate intensity and persistency of diagnostic information for our members. Provide analyses and recommendations in support of these programs.
• Direct the modeling of health claims and population impacts through the application of a risk adjustment methodology including risk scores, risk adjustment funds transfer across health plans, and plan selection, in order to develop and utilize models to evaluate and forecast impact of specific programs and interventions.
• Engage with enterprise functional areas to optimize identification of members/providers for program interventions and ensure all appropriate members are referred to or engaged in care management programs.
• Direct resources to independently design, implement, and maintain SAS programs in line with acceptable statistical methodology, timely and accurate data integration, analysis, and interpretation of results.
• Analyze provider coding trends to identify potential risk gaps, facilitating efficient and effective interventions to ensure accurate and complete coding.
• Prepare executive management summaries on results of analyses, interpreting, communicating, and presenting results to all levels of management in consistent and easy to understand formats to facilitate fact-based decision making.
• Maintain current risk adjustment business rules and control documents, updating code as necessary based on CMS changes and updates.
• Monitor CMS Edge Server error reporting and assist in the triage and correction of errors.
• Represent BCBSAZ on both CMS and Association calls on Risk Adjustment and Edge Server topics.
• Participate in all required audit activities, including oversight of the Risk Adjustment Data Validation Audit program using CMS coding protocols for Retrospective Chart Review and member data validation process.
• Develop targeting logic for Risk Adjustment/Performance Programs, monitors year over year performance on the overall Performance impact. Drives strategy for program mix and investment to financial leadership at trade partner Joint Operating Committees.
• Serve as an internal IU consultant to define business questions, transform data and analysis into meaningful and actionable information for a variety of customer segments and help end users interpret and apply analytic results.
• Oversee the CMS EDGE and Supplemental end-to-end submission process, collaborating with internal operations and technology business partners to ensure all data is properly processed and reflected in the submission.
• Provide essential analytic support to fulfill state and national mandated reporting requirements.
• Lead the development of new performance measurement tools and approaches and maintain up-to-date knowledge of emerging measurement standards.
• Ensure accuracy of reports using self- and peer-review and by independently resolving discrepancies.
• Complete ad hoc requests to support all business needs.
• Oversee day-to-day departmental administration by coaching and motivating staff and departmental personnel to make maximum use of experience and skills.
• Plan and lead complex projects from inception to completion. Includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring post-implementation issues.
• Build and maintain effective working relationships with internal stakeholders and key external stakeholders, including providers, vendors, brokers, BCBS Association, blues plans, auditors and regulators, to ensure compliance and achieve plan goals.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.