Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

AVP, Enterprise Risk Adjustment and Data Integrity

📁
Director and Equivalent
📅
1912N Requisition #
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Develop and execute a comprehensive enterprise-wide revenue management strategy that improves the quality of care delivered to Emblem members and to ensure the plan reimbursement accurately reflects the clinical diagnosis of our Medicare, Medicaid, and ACA members across the enterprise.  Drive partnerships with providers to improve accuracy of their diagnoses coding through the education of our risk adjustment programs, incentive models and ongoing development/enhancement of support capabilities that complement their clinical practice model.  Select and manage best in class vendors to drive continual improvement in the accuracy of diagnosis coding for Medicare, Medicaid and ACA members.  Direct the ongoing performance, compliance and return on investment for each vendor.  Create and manage a capabilities framework that is member and provider-centric and is appropriate given for the clinical and demographic dynamics of members in risk adjusted products.  Ensure the integrity of encounter data submissions for Medicare, Medicaid, and ACA.  Identify opportunities to partner with EmblemHealth medical management, quality, marketing & sales and network departments to achieve efficiencies and improve effectiveness by integrating both prospective and retrospective programs with care management, CMS Stars, Medicaid and Health Exchange quality programs, sales outreach and provider contracting.

Responsibilities:
  • Drive successful execution of risk adjustment strategy and activities for the enterprise for Medicare, Medicaid, and ACA. 
  • Ensure that revenue goals associated with risk adjustment programs are achieved.
  • Improve revenue accuracy of premium reimbursement from CMS and NYSDOH.  Activities can include, but not limited to, vendor performance, provider engagement, and delegated provider oversight of risk adjustment performance, and implementation of an appointment setting strategy. Enhance results for integrating activities with Quality and ACPNY to enhance quality results.
  • Select and manage best-in-class vendors to drive continual improvement in the accuracy of diagnosis coding for Medicare, Medicaid, and Health Exchange members.
  • Ensure provider programs and strategies are state of the art and effectively implemented.
  • Implement and monitor risk adjustment vendor performance and vendor adherence to service level agreements.
  • Responsible for the ongoing performance, compliance and return on investment for each vendor. 
  • Create and maintain a capabilities framework that is member and provider centric and is appropriate given for the clinical and demographic dynamics of members in risk adjusted products.
  • Ensure vendor performance related to risk adjustment activities is optimized including performance, ROI and budget.
  • Direct an enterprise-wide team to complete revenue opportunities for Medicaid, Medicare and ACA products which includes identification of risk score opportunities, suspects, analysis and tracking of performance and attribution of interventions.
  • Continuously identify new opportunities for revenue enhancement.
  • Responsible for the Medicaid, Medicare and ACA encounter data submissions and integrity programs including ensuring timely and accurate submissions, identification of system improvements in data extraction and submission, data retention and tracking controls that will improve the number of submitted transactions and reduce the error rate; manage the interdepartmental error correction process. 
  • Maintain and improve the submission process which may be driven by changes to SDOH and CMS compliance rules, new risk adjustment methodology and models, or modifications to the plan claim payment systems and processes. 
  • Represent EmblemHealth and act as subject matter expert with the State and CMS for all risk adjustment issues and compliance.
  • Drive and improve programs across the enterprise to retrospectively identify, retrieve, code and submit diagnostic information from providers on members enrolled in Medicare, Medicaid, and ACA products.
  • Partner with providers to improve the accuracy of their diagnosis coding through education of our risk adjustment programs, incentive models and the ongoing development/ enhancement of support capabilities that complement their clinical practice model.
  • Manage revenue accuracy team which will directly oversee ongoing processes related to risk adjustment data accuracy which will include prospective, concurrent, and retrospective targeted audits focusing on High Volume, At Risk CRG/HCC’s, Risk Providers, random samples, management and oversight of vendor/s that support for internal and external RADV audits Management of risk adjustment audit data repository.
  • Drive and deliver an enterprise-wide provider strategy for risk adjustment coding requirements to high volume providers, vendors, global capitation and ACP group leadership to ensure that there is a comprehensive understanding of requirements for documentation, which vary for CMS, SDOH and HHS.
  • Create and direct the management of all aspects of a revenue management incentive program.
  • Direct interaction with the CFO, CEO and other physician leaders of ACP groups and other large, sophisticated medical groups to integrate our programs into the providers operations. 
  • Develop, implement and oversee revenue accuracy auditing and monitoring programs for Health Exchange, Medicare and Medicaid products, including prospective, concurrent, and retrospective targeted audits, ongoing risk analysis and identification of systematic interventions to improve accuracy.
Qualifications:
  • Bachelor’s degree required
  • Master’s Degree strongly preferred
  • 10+ years progressive leadership responsibility and experience in managed care, with a focus on government or state sponsored product lines required
  • Minimum of five years’ work experience in government programs related to risk adjustment required
  • Expert knowledge of CMS Medicare and Medicaid Risk Adjustment requirements and reimbursement methodologies required
  • Experience with leading payer member recertification activities for Medicaid and Medicare lines of business required
  • Exceptional business acumen and analytic skills required
  • Demonstrated ability to understand and articulate complex business strategies into tactical plans and drive execution of established work plans required
  • Strategic and tactical abilities in troubleshooting and solving persistent operational impediments required
  • Proven ability to coordinate and lead interdepartmental work teams and meet established goals required
  • Must be goal oriented and able to meet tight deadlines while handling multiple priorities required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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