Director, Risk Adjustment Strategies and Initiatives

Salary Range

Min.$149,502.00 Mid.$201,827.00 Max.$254,152.00

About the role

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Responsibilities

• Supports the organizational, management and development of risk adjustment programs for L.A. Care’s risk adjusting lines of business (LOB).
• Conducts strategic planning to utilize resources to meet current and future departmental and Enterprise-wide goals.
• Develops and executes a risk adjustment strategy aligned to organizational goals, regulatory requirements, and performance targets.
• Leads cross-functional initiatives to improve diagnosis accuracy, coding capture, and documentation quality across settings.
• Establishes and manages program governance, workplans, timelines, and reporting for risk adjustment initiatives.
• Designs, implements, and monitors and refines solutions and strategies to effectively improve the capture of accurate and comprehensive risk adjustment scores and continuously improves organizations’ STAR rating.
• Identifies and actualizes enhancements to support company vision.
• Develops, evaluates, enhances and ensures physician and/or other incentive programs are targeted and highly effective.
• Directs programs supporting compliant coding and documentation practices, including prospective, concurrent, and retrospective review models.
• Oversees and continuously improves the operations and effectiveness of the organizations’ AWE efforts.
• Manages risk adjustment vendors (chart retrieval, coding, suspecting, analytics tools, provider education) including performance SLAs and outcomes.
• Partners with analytics teams to identify opportunities through data mining, predictive suspecting, and performance segmentation.
• Translates complex data into actionable recommendations and executive-level updates.
• Leads discussions on policy operationalization and oversees key policy perspective sharing.
• Prepares briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's regulatory position and policy.
• Develops regulatory position and policy based on research and evidence.
• Maintains and assesses the risk adjustment and Medicare STAR landscape to identify opportunities and determine program needs, tools, etc. to support the organization’s objectives, physicians and other partners in these programs in understanding the risk adjustment payment model and Medicare STAR program.
• Responsible for bringing forward and developing/implementing tools or other activities to support organizational goals.
• Collaborates with other staff, as necessary, to finalize initiatives and provide internal, provider and other training, as needed.
• Manages multiple initiatives and projects and uses project management techniques, including project plans, plan or activity oversight, schedules, task force and/or other meetings, timelines, etc., to ensure initiatives are implemented in a timely manner, completed on time and achieve organizational objectives.
• Troubleshoots issues with internal colleagues, committees, task forces and/or other departments to ensure risk adjustment and Medicare STAR activities are pursued assertively and barriers to performance are identified quickly and solutions developed and implemented.
• Resolves and/or escalates critical issues that impact timelines or success in a timely manner.
• Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.
• Fosters and promotes a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.

Requirements

• Bachelor's Degree in Business Administration or Healthcare Management or Related Field
• At least 8 years of experience in risk adjustment
• Strong knowledge of Centers for Medicare and Medicaid Services (CMS) Risk Adjustment and ICD-10 coding requirements and regulations
• At least 6 years of leadership and management experience
• At least 5 years of experience in the healthcare setting

Qualifications

• Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
• Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization
• Demonstrated ability to make sound and timely decisions
• Demonstrated ability to adapt to changing situations and adjust strategies accordingly
• Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change
• Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations
• Strong understanding of risk adjustment operations: chart retrieval, coding, provider education, suspecting, reconciliation, and audit preparation
• Proven ability to lead cross-functional initiatives and influence stakeholders at multiple levels
• Strong presentation skills
• Proficient in Microsoft Office

Skills

• Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
• Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization
• Demonstrated ability to make sound and timely decisions
• Demonstrated ability to adapt to changing situations and adjust strategies accordingly
• Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change
• Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations
• Strong understanding of risk adjustment operations: chart retrieval, coding, provider education, suspecting, reconciliation, and audit preparation
• Proven ability to lead cross-functional initiatives and influence stakeholders at multiple levels
• Strong presentation skills
• Proficient in Microsoft Office