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Department

Remote opportunity for residents of Colorado, Illinois, Kentucky, Mississippi, New Hampshire, Ohio, Pennsylvania, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin. 

Job Summary
Under minimal supervision, creates, analyses, monitors and manages the strategy and operations of Medicare and Affordable Care Act/Exchange Risk Adjustment team for Denver Health Medical Plan. This position oversees Medicare and Affordable Care Act/Exchange risk adjustment and translates DHMP strategies into operational plans and direction and they pertain to revenue, numerous quality measures and reporting submitted to regulators. This position serves as the Risk Adjustment subject matter expert and will ensure the accurate, timely and compliant execution of all Risk Adjustment activities and achievement of related revenue targets. This position will interact with all levels of management and employees, external consultants and Federal and State representatives.

Essential Functions:

• Manages the development, implementation, monitoring and oversight of programs, processes and operations to improve risk adjustment performance and accuracy of risk adjustment data collected and submitted to State and Federal regulators.
• Oversees Chart Review, Home Health and Encounter Data vendors and creates strategic plans for risk capture activities and assess ROI for risk adjustment program activities; develops effective relationships with key provider groups (internal and external).
• Ensures accurate development, analysis and reporting of key risk adjustment metrics, as well as overseeing analyses of new legislation and regulations regarding Risk Adjustment; evaluates and oversees the development and implementation of all risk adjustment program changes. Incorporates changes and requirements into strategy.
• Develops and monitor STAR and other quality metrics and works with business owners to ensure goals are achieved.
• Develops oversight programs to ensure compliant capture of data related to Risk Adjustment revenue, including Encounter Data, various quality measures and member status related to revenue.
• Coordinates with appropriate functional areas including Medical Management, Quality, Pharmacy, Member Services, Operations, etc. as it relates to Risk Adjustment initiatives.
• Coordinates with Quality Improvement (teams to ensure coordination of efforts; collaborate to ensure delivery and integration of risk adjustment and quality programs.
• Partners with contracted service providers, internal departments and plan leadership to plan the strategic direction of risk adjustment initiatives to facilitate achievement of complete and accurate diagnosis capture and sustainable business performance to achieve organizational goals.
• Uses analytics to define Risk Adjustment focus and optimizes quality and risk adjustment metrics opportunities. Leads the development of key analytics and data to support risk adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization.
• Develops performance targets for both internal and external parties and ensures that performance targets are set and included in contracts where appropriate. Tracks progress against stated goals and drive to attainment.

Education:

• Bachelor's Degree Required

Work Experience:

• 4-6 years of five years Risk Adjustment and/or Managed Care or Health Care experience required.

Licenses:
Knowledge, Skills and Abilities:

• Solid knowledge of the industry and cross-functional work experiences in the areas health insurance finance, medical economics, actuarial, underwriting, and/or risk adjustment.
• Strong analytical skills.
• Subject matter expert for proper risk adjustment coding and CMS data validation.
• Expertise in reconciliation and revenue enhancement principles.
• Proven ability to make sound decisions relative to the reconciliation and revenue enhancement of Medicare Advantage products.
• Demonstrated interpersonal, communications and team building skills.

Shift

Work Type

Salary

Benefits

• Competitive pay

• Outstanding benefits

• Education opportunities

• Shared leadership and advancement opportunity

• State-of-the-art facilities

• Immediate retirement plan matching

• Professional clinical advancement program

• Participation in evidence-based projects

• Public Service Loan Forgiveness (PSLF) eligible employer

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For read more about our commitment to diversity visit: https://www.denverhealth.org/for-professionals/careers/diversity-and-inclusion

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About Denver Health

Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.

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