Manage revenue optimization initiatives for the PacificSource Medicare line of business. Working with senior leadership, finance, and operating units, responsible for developing annual goals for Medicare revenue enhancement and overseeing the various work products to ensure goal attainment. Specific accountabilities within the job include program development, program management, vendor oversight, and oversight of the business intelligence necessary to drive optimal performance in revenue management. Work closely with the Senior Vice President of Government Programs and the VP of Finance, as well as numerous other internal departments, contracted vendors, and provider partners.
Manage end-to-end Medicare Revenue optimization initiatives for PacificSource Medicare Advantage plans. Lead cross functional Medicare revenue teams. Oversee contracted vendor activities and overall performance in the areas of risk adjustment, coding improvement, chart review, and reconciliation.
Work with leadership and operating units to develop annual goals for revenue enhancement and coding improvement.
Develop and direct implementation of Medicare Risk Adjustment Strategic Plan in cooperation with key business partners including provider medical groups, coding, information systems, and risk adjustment team, and finance department. Develop and oversee implementation of the various risk adjusted revenue initiatives.
Ensure risk adjustment and revenue enhancement activities are in strong alignment with PacificSource values, positive provider engagement, and improving care to our members.
Develop and maintain best practice member accounting and CMS reconciliation processes.
Interface with Pharmacy Benefits Manager vendor to ensure accurate Part D reconciliation procedures.
Develop and deliver presentations to senior leadership, operating unit managers, and other on program performance, goal attainment, and ongoing improvement opportunities.
Responsible for the systematic implementation and oversight of Medicare HCC program, including management reporting, communication, and coordination of initiatives related to Medicare HCC.
Functions as key liaison and provide support on revenue management initiatives, best practice principles around contract negotiations efforts, and lead policy/process to affect organizational change to improve efficiency and profitability.
Manage vendor relations and activities to meet department goals. Develop and implement business plan to supplement the vendors’ revenue management activities using internal staff. Oversee internal and external stakeholders ensuring Medicare coding is accurate and correct.
Oversee extracting and collecting diagnosis data from claims systems, submitting this data in the form of Risk Adjustment Processing System (RAPS) files to CMS in a timely manner, and oversee the RAPS record error correction processes. Perform projections, analysis and monitoring for both complex risk adjustment projects and ongoing operations.
Monitor and analyze risk score trends. Work with IT and Actuarial staff to reconcile data with Medicare financials, forecast risk adjustment factors, and model impacts of potential payment changes.
Interact with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, Marketing & Sales, IT, AUA, and Compliance. Coordinate business activities by maintaining collaborative partnerships with key departments.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Actively participate as a key team member in manager/supervisor meetings.
Assists in annual Medicare Bid process.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: 5 years in healthcare and 3 years risk adjustment experience. Knowledge of CMS risk adjustment and pricing mechanics.
Education, Certificates, Licenses: Bachelor’s Degree in related field required.
Knowledge: Advanced knowledge of CMS regulations governing Medicare reimbursement. Demonstrated leadership in program development and management; 3 years cross-functional management experience.
Building a Successful Team
Aligning Performance for Success
Driving for Results
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We encourage creativity, innovation, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity and affirmative action employer.