Director, Risk Adjustment Programs

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.Position Purpose: The Director of Risk Adjustment Programs is a key member of the Risk Adjustment Team, coordinating both internal and external activities to achieve revenue appropriateness objectives. The Director of Risk Adjustment Programs is the subject matter expert (SME) that provides guidance for vendor-related issues and overall program management for the risk adjustment programs including, but not limited to, retrospective and prospective initiatives.

Manages risk adjustment programs and initiatives to help achieve the revenue appropriateness goals and objectives.

Manages the activities of outside vendor partners by directing risk adjustment outsourcing strategies & governance.

Monitors the vendors’ service level agreements (SLAs) and goal attainment.

Continually assesses program costs and containment.

Collaborates inter departmentally to help facilitate enterprise-wide vendor alignment efforts.

Works with WellCare’s provider network (IPAs and independent providers), regional provider relations’ networks, and other key personnel to help resolve medical record acquisition issues (i.e. barriers to access to the health records).

Manages outsourced vendors to meet contractual obligations and to abide by signed Statements of Work (SOW).

Acts as the Risk Adjustment Team business voice during vendor contract negotiations.

Provides financial and quantitative analysis of program costs by extrapolating internal and vendor expenses.

Manages vendors and internal Risk Adjustment Team to budget.

Works with Health Analytics to project overall program returns on investment (ROI).

Develops and implements Corrective Action Plans (CAPs) when necessary in order to obtain successful risk adjustment program completion and expected ROIs.

Develops tools for resource planning and management including Key Performance Indicators (KPIs) for program success. This includes helping to develop staffing volume assessment models for program goal attainment. Examples include internal and external staffing requirements needed to successfully complete CMS’ Jan. 31st sweep date, Risk Adjustment Data Validation (RADV) deadlines, vendor home visits programs, special pilot studies, inter-departmental medical record audits (MRA/AMRR), etc

Manages the CAP process by providing domain expertise when responding to the Regulatory and Compliance Departments for CMS and/or other governing bodies’ submission requests.

Develops and implements Standard Operational Procedures (SOPs), work flows, and process documentation policies for risk adjustment programs.

Represents the Risk Adjustment Team’s viewpoint and manages departmental projects to meet deliverables for CMS-directed initiatives such as ICD-10 conversion, HIPAA 5010 implementation, CMS workgroup participation, and CMS industry update meetings.

Manages relationships externally with each vendor partner, leveraging each relationship and spearheading co-development initiatives.

Builds and maintains strong relationships internally, fostering support and a collaborative approach between departments with internal stakeholders. This includes, but is not limited to, collaborating with each individual market/region, working closely with the Provider Relations Network, communicating with Marcomm & Regulatory, working with Product Management, partnering with the Health Services Department, and teaming up with the Business Process Improvement (BPI) Department.

Candidate Education: Required A Bachelor's Degree in in a health related field and/or financeRequired or equivalent work experienceCandidate Experience: Required 7+ years of experience in managed care, HEDIS, Risk Adjustment and/or other healthcare initiatives. 3 of which in supervisory/management rolesLicenses and Certifications: For Collaborative Health Systems: Certified Project Management Professional (PMP)-PMI: PreferredPay Range: $103,500.00 - $191,600.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.