Director, HCC/RAF Incentive Programs

US-CA-Los Angeles
Job ID
2017-4487
Category
Managed Care

Overview

Develop, implement and monitor AltaMed's HCC RAF strategies across the enterprise. Responsible for the entire life cycle of HCC RAF scores from assessment to submission and verification of policies and procedures to ensure excellent transmission. Assess current procedures across the enterprise and make recommendations for enhancement, standardization and data gathering optimization. Present and promote the Alta Med HCC/RAF strategy to clinic administrators, IPA physicians and other parties. Provide and explains performance data. Monitor and create corrective action plans to assist the physicians or offices that perform below benchmark. Oversee the performance of the person(s) and vendors in charge of chart audits, home visit assessments and the performance of internal resources devoted to the HCC/RAF efforts.

 

Responsible for ensuring that AltaMed’s risk adjustment programs is compliant with Centers for Medicare and Medicaid Services (CMS) and State and federal regulatory requirements.

 

Responsibilities

RESPONSIBILITIES:

  • Accountable for outstanding customer service to all external and internal customers.
  • Develops and maintains effective relationships through effective and timely communication.
  • Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.
  • Design, develop, implement and manage a comprehensive Hierarchical Condition Category (HCC)/Risk Adjustment Factor (RAF) strategy for the organization including:
  1. Data mining strategies for members covered under risk-based models (i.e. Medicare Advantage Plans).

  2. Developing organization-wide data collection methodology and an effective HCC/RAF coding program.

  3. Standardization of HCC/RAF workflows, including monitoring and improvement of error rates and timely submission.

  4. Plans to ensure successful completion of internal/external risk-adjustment data validations (for RADV Audit).

  5. Training program for network providers and staff to ensure valid HCC documentation.

  6. Coordinate training network provider and staff training required to address knowledge gaps and new HCC/diagnoses identified as opportunities.

  7. Develop and maintain an expert level of knowledge of Medicare and risk-based reimbursement methodologies.

  8. Makes recommendations to Clinic Administrators/Physicians as to how to best support the HCC/RAF optimization strategies.

  9. Develop and strengthen relationships with provider partners to achieve improvements in risk adjustment program participation and data validation.

  10. Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.

  11. Oversee and improve the processes that capture encounter data and ensure appropriate submission to CMS.

  12. Develop forecasting methodologies that translate data mining initiatives (coded data) into revenue estimations for annual budgeting process.

  13. Develop and implement a frequent data reconciliation process between AltaMed and all senior health plans.

  14. Monitor individual physician and clinic performance for key HCCs and diagnoses, providing leading indicator data and standard reports to the physician practices on current performance.

  15. Present HCC/RAF performance results and findings regularly to physicians and clinic administrators, including the overall HCC/RAF score, improvement strategies and tactics.

  16. Maintain high functioning staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.

  17. Serve as risk adjustment coding subject matter expert for Medicare plans and corporate HCC/RAF outreach teams.

  18. Promote a provider-friendly, customer service oriented philosophy within the HCC/RAF department.

  19. Provides leadership and coaching to all direct reports and partners with human resources on employee matters.

  20. Works with employees to develop clear and concise development plans to ensure the advancement of future leaders within AltaMed (succession planning).

  21. Ensures standardization of HCC/RAF related workflows, including monitoring and improvement of error rates and timely submission.

  22. Present HCC/RAF performance results and findings regularly to physicians and clinic administrators, including the overall HCC/RAF score, improvement strategies and tactics.

  23. Coordinate with training director on documentation and trainings required to address knowledge gaps and new HCC/diagnoses identified as opportunities.

  24. Model and monitor RAF and risk adjusted revenue PMPM by plan/patient cohorts and review cost and utilization trends to understand impact on revenue

  25. Monitor HCC program initiatives relative to benchmarks/targets

  26. Provide reporting and analysis of revenue results to assist financial reporting, forecasting and budget development teams

  27. Develop tools to evaluate accuracy and completeness of encounter exchange with capitated providers

 

Qualifications

  1. Bachelor's degree in Business Administration , Economics, Operations Research, Public Health, Health Administration or other related field required

  2. Seven (7) years of experience in project management, general management and/or consulting required

  3. Seven (7) years of experience in managed care

  4. Five (5) years of experience in CMS Risk Adjustment Methodology and/or implementing and overseeing HCC/RAF programs

  5. Healthcare experience in a health plan, medical group or hospital setting preferred

  6. Five (5) years of experience managing direct staff or departmental management experience

 

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