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.

Manager, Risk Adjustment Programs

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Manager & Professional
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EmblemHealth
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Responsible for managing all EmblemHealth efforts related to the development and execution of provider risk adjustment program for all three government lines of business (Medicare, Medicaid and ACA) for Emblem provider groups / partnerships. Provide oversight of a team of risk adjustment Provider Engagement Specialists; drive provider intervention strategies that will produce successful risk adjustment outcomes related to risk scores and improved prevalence of accurate and complete member diagnoses capture. Collaborate with Leader to develop an extensive set of risk adjustment provider tools and enablement strategies such as coding and documentation education, reporting on key risk adjustment metrics, and integrating the risk adjustment activities with other EmblemHealth business units. Utilize an expert understanding of risk adjustment methodologies, ability to implement provider programs for risk score improvement, and ability to engage providers at all levels. Oversee risk data analytics related to the provider engagement team; create tiered levels of engagement tactics. Serve as a risk adjustment lead to our network to report on risk score performance as well as to identify opportunities for further collaboration on risk adjustment programs. Serve as a managerial liaison between EmblemHealth and Emblem’s Risk Adjustment vendors for efforts related to the Medical Record Review process; provider outreach submission of provider alerts; and provider education on proper coding and documentation. Identify areas for improvement and routinely monitor success of the risk adjustment provider engagement model (e.g., monitoring and ensuring accuracy of the daily Disposition and Pre/Post-visit reports).


Responsibilities:

  • Manage the day-to-day activities involving the Provider Engagement team and Vendor compliance functions for Emblem Medicare, Medicare, and ACA members. This will include, but is not limited to, managing the risk adjustment provider Clinical Documentation Initiative process, educating providers on the importance of complying with medical record requests, developing and disseminating provider communications, and other activities related to risk adjustment and any other program expansions.     
  • Work with Department Leader to develop, implement, drive, and monitor activities of the Risk Adjustment Department to maximize revenue.  
  • Direct activities to ensure continued expansion and efficient functioning of prospective and retrospective processes while ensuring dissemination of information to providers to enable their provision of care within the framework of established policy and procedures.    
  • Perform analysis of program critical success factors and identify opportunities for improvement to stratify existing outreach initiatives and identify new program opportunities. 
  • Coordinate and develop prospective operational analytical strategies for participating providers.  
  • Ensure the accuracy of electronic management of provider information for the purposes of targeted outreach.    
  • Assist in Project management activities including coordination of interdepartmental communications such as with Finance, Submissions, and Actuarial.  
  • Provide monthly updates on the progress of various projects, both operationally and financially.    
     

Qualifications:

  • 5 – 8 years’ experience in Healthcare, plan or provider operations/relations, or related area (R)
  • Strong customer service experience (R)
  • Experience with data analytics/mining, report creation, and managing databases  (R)
  • Excellent organizational, project management, and relationship management skills (R)
  • Excellent verbal, written, and presentation communications skills (R)
  • Ability to manage time and work efficiently to meet deadlines with minimal supervision (R)
  • Proven ability to deliver complex information and achieve positive results (R)
  • Strong decision-making and problem-solving capabilities (R)
  • Capacity to Multi-task at high detail-oriented level (R)
  • Proficient with MS Office applications (Word, Excel, Powerpoint, Outlook) (R)
  • Solid analytical and logical skills paired with strong attention to detail (R)

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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