Director Regional Risk Adjustment Programs - Military veterans preferred

Administrative Support


  full-time   part-time   employee   contract

United States

JOB SUMMARY: Responsible for planning, directing and strategic oversight of the programmatic functions of the Pacific Northwest’s risk adjustment, accurate coding and diagnosis, Quality and Affordability programs (RAQ) for risk based contracts (including Medicare Advantage and Dual Eligible, Accountable Care Organizations (ACOs), commercial or Medicaid capitation, and any other value-based performance reimbursement with chronic conditions) in new and developing markets in the Pacific Northwest region. Responsible for the assessment, gap analysis, operational planning, deployment and management of RAQ programs for prospective and/or developing markets. Under the direction of the Vice President of Risk Adjustment & Quality Integration, the Director develops multi-year strategies and tactics to ensure high performing RAQ programs for PNW’s growth markets.ESSENTIAL DUTIES & RESPONSIBILITIES: The duties listed below are intended only as illustrations of the various types of work that may be performed.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment.Support the development and implementation of a system that delivers great patient care consistent with the quadruple aim for all value-based programs.Develops strong relationships & supports the assessment, gap analysis and integration plans for prospective affiliate partners and acquisitions as part of the diligence processImplements & manages RAQ programs in partnership with market leadership & PNW Value team leadership in the areas of Risk Adjustment, Quality and AffordabilitySupports network growth through strategic expansion of the PNW region’s value-based care contracts. This strategy includes ensuring the appropriate infrastructure and support of any new member lives through affiliate relationships and programs, the implementation of wrap around services, and member outreach.Oversees risk adjustment, quality, and affordability initiatives in our growth markets, including health assessment initiatives, HCC risk adjustment data & documentation integrity, and supporting vendor programsSupports the assessment, implementation, and management of attestation programs to promote complete and accurate coding & documentation activities at the point of care.Coordinates implementation of programs designed to ensure all diagnosed codes and conditions are properly supported by appropriate documentation in patient chart.  Programs include but are not limited to: training and educational activities, clinical support programs, retrospective reviews, submission, reconciliation, and electronic data submission.Oversees patient engagement and outreach to facilitate comprehensive health assessment for Medicare Advantage patient population, and other managed or risk-based populations.Selects and manages vendors for programs such as in-home health assessments, embedded NP, screening tools, medical chart retrieval, and medical coding.Assists in the design of incentive and reimbursement programs for group constituents to incentivize appropriate coding and documentation practices related to RAQ activity.Coordinates development of training content for risk adjustment, quality, and clinical documentation guidelines.Coordinates with clinician leadership to ensure the clinical aspects of RAQ and best practices are communicated to providers.Supports implementation of programs designed to ensure all diagnosed codes and conditions are properly supported and submitted to Health Plan partners.  Programs include submission, reconciliation, and electronic data submission.Identify and analyze implications of key changes to the regulatory & policy environment on provider organizations in the areas of risk adjustment, quality, and compliance.Support effective business relationships with external entities, including payers and health plan partners with continuous focus on performance improvement related to population clinical quality and patient experience goals.Organize and provide executive, management and front-line initiatives and performance reporting and communication for any manages programs.Prepares timely and accurate monthly and annual reporting as required.Requires significant collaboration with internal stakeholders including, but not limited to, primary care section and specialty service lines, IT, business services and finance, contracting, compliance, as well as external entities and vendors will be required.Provide supplemental expertise and bandwidth in existing regional markets, as needed.Leads, manages and mentors RAQ managerial and project management staff to support OptumCare achievement of deliverables on documentation completeness and accuracy, clinical quality and patient experience. Uses evidence-based, consistent practices in coordination with external entities and guidelines.Evaluates the performance of direct report(s), including performance to identified standards and metrics for the team.Consistently exhibits behavior and communication skills that demonstrates Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer.Duties listed below are integrated into all job functions:All staff members are to promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing his or her job responsibilities and conducting themselves in a professional, courteous and respectful manner toward fellow employees, physicians and patients.Must be facile at operating independently in new and ambiguous market scenariosMust relate to other people beyond giving and receiving instructions: (a) get along with co-workers or peers without exhibiting behavioral extreme; (b) perform work activities requiring negotiating, instructing, supervising, persuading or speaking with others; and (c) respond openly and appropriately to feedback regarding performance from a supervisor.Performs all duties in a manner which promotes and supports the Core Values and Compact of.Integrates Lean principles, practices and tools to improve operational efficiency, reduce costs and increase customer satisfaction.Frequently must follow written and oral instructions as well as complete routine tasks independently.Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signs Agreements.Ensures confidentiality of patient information following HIPAA guidelines and OptumCare policies.Attends training to meet requirements of the job position and as needed or mandated by OptumCare policies, Div. of Occupational Safety & Health (DOSH), OSHA, L&I and other state/federal regulations.Has regular and predictable attendance.Performs other duties as assigned.PREFERRED QUALIFICATIONS: Knowledge, Skills & Abilities: Note that these requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required to perform this job.Experience leading risk adjustment activities in a large Medicare HMO or provider organizationAbility to interact effectively with C-Level employees across the organizationKnowledge of regulations related to Medicare Advantage, Medicaid, Commercial risk adjustmentKnowledge of claim coding and payment methodology utilized in Medicare and Medicaid lines of businessStrong leadership capabilities, and ability to initiate and maintain cross-team relationshipsExcellent analytical, actuarial, and problem-solving skillsAbility to effectively direct preparation of various financial analysis and data mining activitiesAbility to effectively interface with staff, clinicians and managementExcellent teaming/interpersonal and verbal and written communication skillsEducation: Bachelor's degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.  Master’s degree in Healthcare Administration, Business Administration preferred.           Experience: 5 years and up to and including 10 years of experience in a healthcare setting.  Over 3 – 5 years of management experience.  Experience in analytics and data analysis. Preferred background in supporting risk adjustment & quality activities, clinical informatics, and fluency in Microsoft applications.Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.