The Risk Adjustment Program Specialist supports day to day operations of the Risk Adjustment Programs and functions. The role guides programs aimed to increase physician and front office awareness of risk adjustment. Implements tools to improve and measure medical group and physician performance. Ensures proper benchmarks for various programs are monitored to ensure program effectiveness. Working closely with the department manager and staff, coordinates the organization strategies and initiatives related to Risk Adjustment Programs. Helps support contractual agreements with Health Plans including Medicare Advantage, ACOs, Medicare, and PPO collaborations.
Under minimal supervision, independently oversees risk adjustment programs designed to meet the organizations and physician performance needs. Presents progress and outcome reports monthly, quarterly and annually to management.
Oversees the maintenance of comprehensive software tracking and management tools to support Risk Adjustment Program. Essential to have knowledge of Brown & Toland software tracking and management tools including but not limited to: Allscrips Enterprise (EMR), BT C.A.R.E. RevenueMax, Optum-Ingenix Insight, Cognos, Senior Outreach Tracking Database, various Health Plan HCC tracking tools, intimate understanding of the HCC Dashboard measures, and ability to coordinate and/or work alongside IT departments internally and externally.
Manages, supports, and provides remarkable physician service, problem tracking and resolution to ensure high quality professional communication and service to the network. Independently resolves issues with high complexity.
Ensures accuracy and timely delivery of documents and files, including encounter data, to meet industry deadlines. Collaborates with outside vendors to produce findings in timely manner for quality review prior to submissions to Health Plans. Manages progress of IT submissions as well as monthly submissions for senior line of business with Health Plans. Reviews monthly reports to ensure organization meets Health Plan thresholds for encounter data submissions. Identifies tools from clearing houses and Health Plans to assist organization to work encounter edits to improve quality of submissions.
Monitors key indicators and benchmarks within specific specialties and primary care physician practices to discern influencing factors within the utilization infrastructure and HCC. Identifies outlier/non-compliant physicians and works with management to create programs to enhance their performances. Continually works to improve program processes.
Acts as a liaison and resource to the organization, physician network, Health Plan Risk Adjustment departments, and third party vendors, including leadership internally and externally. Recommends changes if needed to improve the organization’s HCC performance and patient satisfaction. Act as secondary point person for delegated vendor oversight activities.
Creates, updates, and enhances materials to assist physicians and staff on Risk Adjustment Programs. Collaborates with analysts and other department members to customizes education and education materials for various audiences including support staff, primary care physicians, specialists, billers, coders, and employees of other healthcare delivery systems.
Collaborates and partners with Physician Services in monitoring and evaluating physician performance within the Risk Adjustment Programs and develops action plans to enhance physician performance. Creates reports and oversees chart reviews, attestations, and home visit vendor to enhance physician performance in HCC. Constantly works with physicians and physician offices to improve delivery of appropriate services of healthcare to high acuity members.
Qualifications & Requirements:
Must have intermediate knowledge of Microsoft Access and Excel. Must demonstrate the ability to follow through and meet deadlines. Must display strong problem-solving skills and have excellent oral and written communication skills. Must be able to prioritize tasks and work independently with minimal supervision. Attention to detail and overall administrative skills are essential to this position .
Ability to think creatively and work collaboratively to address problems. Ability to present solutions to multidisciplinary teams.
Ability to write and present reports and presentations. Well developed written and verbal communication skills.
Bachelor Degree or equivalent combination of education, training and experience is acceptable.
One to three years of applicable experience in Health Care setting to include coordinating Risk Adjustment Programs; experience with working across multiple departments with a variety of employees to achieve program goals.
Brown & Toland, based in San Francisco, is an independent practice association (IPA) of more than 850 community physicians serving 300,000...