Risk Adjustment Program Manager

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

We are looking for a professional with experience in Risk Adjustment for the Medicare, Medicaid, and Qualified Health Plan (“Exchange”) populations. As a Risk Adjustment Program Manager, you will analyze our encounter submissions and identify errors, develop strategies to close risk score gaps, and coordinate the work of internal and external partners focused on driving accurate diagnosis coding and complete claims submission.

This role is ideal for anyone with experience in Risk Adjustment ready to take the next step in their career at a leading not-for-profit health insurer focused on improving the health of all New Yorkers.

• Ensure high-quality encounter submissions: Analyze submission reports prepared by our actuaries to determine the impact of submission errors. Use CMS response files, vendor reports, and internal claims data to determine the source of errors. Work with key stakeholders to resolve issues and resubmit files.
• Identify and close risk score gaps: Continually monitor member- and provider-facing activities to close risk score gaps, including In-Home Assessments and Medical Record Reviews.
• Use data to refine Risk Adjustment strategy: Assess our Risk Adjustment program by reviewing year-over-year changes in risk score, risk condition persistence and the impact of supplemental data files. Modify and refine Risk Adjustment strategy based on your findings.
• Serve as Subject Matter Expert: Work collaboratively with other departments to ensure Risk Adjustment goals are integrated into MetroPlusHealth operations. Educate departments across the organization about how their activities impact Risk Adjustment.
• Prepare ongoing reporting: Access our Data Warehouse to conduct in-depth analysis of critical issues, including claims, enrollment, and provider coding trends.
• Work proactively with vendors: Monitor vendor and work closely with Risk Adjustment vendors to ensure program goals are being met.

• Bachelor’s degree with a demonstrated interest in Finance, Social Services or Health Care. Master’s degree preferred.
• 5+ years’ experience working in the field of Risk Adjustment at a health insurance company or at a risk-taking provider group.
• Must have experience with at least two of the following models: HHS-HCC (Qualified Health Plans), 3M CRG (New York State Medicaid), CMS-HCC (Medicare).
• Thorough understanding of managed care and health insurance operations.
• Experience modeling member-level risk score impacts of various activities.
• Strong analytical skills, including using SQL or other programming language to query large relational databases.
• Proactive communication style and ability to work with a variety of stakeholders to achieve project goals.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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