Risk Adjustment Manager

| Waltham
A bit about us: 
Devoted Health is a new health care company looking to improve the lives of seniors in America. We are guided by a deep belief that every senior should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being. With aging demographics and rising health costs, this is an industry and problem space that needs today’s best talent working on solutions with high integrity and a long term view. We will improve the lives of seniors by helping them navigate the health care system, by utilizing world-class technology and data to enable a simplified experience, by partnering with top providers for better health outcomes. We are building a stellar team to drive towards our starting point goal to launch a Medicare Advantage plan and clinical services in 2019.
Why Devoted:
Make a difference... a big difference. You will have the opportunity, in a unique and dynamic culture, to be a part of something incredibly meaningful. We’re a disruptive startup with an inspiring mission. Learn and grow alongside our world-class team of healthcare, technology, and data leaders, dedicated to building a health plan and clinical services that care for everyone like they were our own mothers or fathers. Our team and board members have decades of experience in health care entrepreneurship, data, technology, services, and policy. With their support, we look forward to building a health plan and clinical services that will give seniors easy access to the high-quality care they deserve. 
A bit more about this role: 
The Risk Adjustment Program Manager is responsible for the timely and accurate collection, flow and processing of data for risk adjustment activities for Devoted Health. The Manager will establish, monitor, and maintain the processes, systems and services that collect and process the data from claims, encounters, electronic medical records, medical record coding, and other supplemental data sources. Reporting and maintaining SOX compliance is also a responsibility of this position. This role acts as the risk adjustment program subject matter expert. The Risk Adjustment Program Manager works closely with other areas of health plan operations and programs, and ensures risk adjustment data operations are administered accurately, timely and in compliance with CMS regulations.

Role responsibility: 

  • Manage the Electronic Data Processing (EDPS) data submission process and ensure that all available data is accepted by CMS and manage the transition from RAPS to EDPS
  • Knowledge of regulations related to data submissions for Devoted Health
  • Knowledge of RAPS and 837I (5010) formats and file protocols
  • Demonstrated ability to complete complex tasks and data processing reliably on time
  • Implements coaching and training plans
  • Negotiates and maintains vendor contracts and relationships as needed
  • Monitors vendor progress and performance and works to improve vendor performance if needed
  • Assists with developing coding policies and plans long-term plan to use technology and other resources to provide more and better information to network providers
  • Coordinates and develops metrics related to risk adjustment operations to inform leadership on progress of activities and risk adjustment programs
  • Maintains knowledge of applicable current and proposed laws, regulations, and sub-regulatory guidance (e.g., CMS) applicable to Risk Adjustment specifically and general knowledge of Medicare Advantage requirements
  • Drafts and maintains policies and procedures, standard operating procedures, and work instructions
  • Actively researches and stays current with requirements from CMS to ensure that risk adjustment program is in compliance with government regulation
  • Escalate gaps in projects to senior leadership
  • Responsible for assisting leadership with implementation and oversight of risk adjustment and mechanism for projects

Attributes to success:

  • Excellent analytical and problem-solving skills
  • Ability to communicates to both internal and external clients on new developments
  • Enjoy engaging in the outlining of program development and management processes, manages the overall scoping, planning, business requirements gathering and delivery of risk adjustment program activities from idea inception to ongoing support and enhancement
  • Communicate with internal and external stakeholders - progress reporting and vendor management
  • Facilitate sharing of expertise by training other departments in support of risk adjustment program
  • Serves as a mentor for other team members to achieve scalability goals

Qualifications:

  • CPHQ certification preferred
  • 2+ years of experience in Risk Adjustment or related healthcare environment
  • Proven track record of managing partners / vendors 
  • Background in analytics, statistics, data management 
  • Proficiency with risk adjustment methodologies
  • Knowledge of coding, HCCs, risk adjustments concepts, medical record review project management, encounter data management, compliance audit concepts. 
  • Prior experience with CMS risk adjustment projects preferred.
  • Bachelor’s preferred
  • Experience with risk adjustment data validations or equivalent compliance audits

If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you!

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Technology we use

  • Engineering
    • GolangLanguages
    • PythonLanguages
    • TypeScriptLanguages
    • ReactLibraries
    • recomposeLibraries
    • Apollo GraphQLLibraries
    • gRPCFrameworks
    • AWSFrameworks
    • PostgreSQLDatabases
    • RedshiftDatabases

Location

Our sunny office is in the beautiful Watch Factory alongside the Charles River in Waltham. It's easily reachable by commuter train, bus, or bike.
221 Crescent Street, Waltham, MA 02453

What are Devoted Health Perks + Benefits

Health Insurance & Wellness Benefits
Dental Benefits
Vision Benefits
Health Insurance Benefits
Onsite Gym
Retirement & Stock Options Benefits
Company Equity
Child Care & Parental Leave Benefits
Generous Parental Leave
Flexible Work Schedule
Vacation & Time Off Benefits
Unlimited Vacation Policy
Generous PTO
Perks & Discounts
Casual Dress
Stocked Kitchen
Some Meals Provided
Parking
Fitness Subsidy
Professional Development Benefits
Job Training & Conferences
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