Manager, Risk Adjustment Operations and Provider Consulting

Point32Health Manager Position

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

Job Summary

This position will lead the Risk Adjustment Operations & Provider Consulting team responsible for the department's program management, provider engagement and consultation activities supporting the complete and accurate capture of risk adjustment data. To be successful, the Manager will need to rely on strong analytic, consultative and communication skills to develop and execute strategies related projects and programs (internal and vendor-driven) that optimize performance across our provider networks serving Point32Health's Medicare, Medicaid, Duals and Commercial small and individual group markets. This position will leverage qualitative and quantitative information to develop and refine provider specific engagement plans that align with our corporate and business division goals. This position will report to the Director of Risk Adjustment Strategy, Operations and Quality Assurance.

Job Description

The Manager will oversee all provider engagement and reporting activities for risk adjustment programs and initiatives that impact Medicare, Medicaid, and Duals product members. This individual will lead the development and implementation of provider-specific analyses and engagement plans, and design effective risk adjustment optimization strategies for the markets we serve. This individual will oversee the analysis, interpretation and synthesis of medical group specific results and risk score trend information; develop dashboard reporting and a regular schedule for delivering the results of standard (and ad hoc) analyses to improve awareness and understanding of risk adjustment results and the quality, accuracy and identification of member health conditions. The Manager will build relationships and drive risk adjustment engagement with senior leaders at contracted provider organizations.

The Manager will be responsible for risk adjustment program management and key supporting functions including the development, implementation and ongoing management of contracts that require the highest levels of service delivery from external vendors. This individual will regularly review the effectiveness of programs, processes, infrastructure and reporting to identify improvement opportunities and recommend changes to improve program results and effectiveness. The Manager will collaborate with key internal stakeholders (Clinical, Contracting, Provider Partnerships, Actuarial, Procurement and Compliance) to refine prospective and retrospective diagnosis coding programs. This individual will oversee team efforts to assess additional program opportunities that can be procured or potentially developed internally; and take a leadership role in collaboration with Procurement during contract negotiations. The Manager will frequently present upon the effectiveness of risk adjustment initiatives and programs to both internal senior leaders and external stakeholders.

The Manager will support department leadership in strategic planning efforts and annual risk adjustment business plan development. They will drive execution against that business plan while optimizing collaboration between Risk Adjustment and other departments or areas that are external facing such as Contracting, Actuarial, Procurement, Provider Partnerships and Care Management / Clinical Affairs. The Manager will oversee the team's project management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. This individual will utilize performance analysis methods to identify and recommend opportunities for process improvement across the department. The Manager will also help lead the current-state assessments of provider organizations' risk adjustment capabilities in new markets or regions.

The Manager will support department leadership by collaborating across business divisions and functions to coordinate the development and refinement of financial dashboards and reporting that identify and track revenue trends and program results for Medicare, Medicaid, Duals and or Commercial small and individual group market membership. The Manager will collaborate with Actuarial and analytical teams within the department to understand and monitor the financial impact of risk adjustment programs.

The Manager will lead a team of six people (three risk adjustment consultants and three program management professionals). Other duties and projects as assigned.

Qualifications

Certification and Licensure : N / A

Education : Bachelor's degree required. Graduate degree preferred.

Experience : Minimum six years in a progressively responsible role with leadership experience in a complex operational setting or consulting role. Previous experience working in strategy development and implementation, analytical and process improvement in the health care / health plan sector or management consultancy. Experience working with CMS, state agencies, health insurers, medical provider systems and / or risk adjustment desired.

Skill Requirements : Highly organized, self-motivated, detail-oriented, and energetic team player who can also work independently. Analytical thinker with strong consultative skills. Working knowledge of both the medical and business side of health plan and provider operations. Ability to understand and navigate complexity and regulation. Strong leadership skills with proven ability to lead change to accommodate evolving organizational and regulatory processes. Strong communication, influencing and partnering skills at all organizational levels across internal functions and with business and medical leadership at physician organizations. Strong one on one, small group and large group communication skills. Excellent judgment, critical thinking, and decision-making abilities. Strong process management and project management skills. Ability to work with data (including financial data) to identify trends and identify process improvements.

Working Conditions and Additional Requirements

Must be able to work under normal office conditions and work from home as required. Work may require simultaneous use of a telephone / headset and PC / keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule.

Salary Range

$109,060.00 - $163,590.00

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes : Medical, dental and vision coverage, Retirement plans, Paid time off, Employer-paid life and disability insurance with additional buy-up coverage options, Tuition program, Well-being benefits, Full suite of benefits to support career development, individual & family health, and financial health.

We Welcome All

All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert

Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org.