Risk Adjustment Resume Samples
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Risk Adjustment Resume Samples
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AZ
A Zemlak
Arvid
Zemlak
6992 Zemlak Locks
Philadelphia
PA
+1 (555) 367 8340
6992 Zemlak Locks
Philadelphia
PA
Phone
p
+1 (555) 367 8340
Experience
Experience
Chicago, IL
Manager, Hedis & Risk Adjustment
Chicago, IL
Lynch LLC
Chicago, IL
Manager, Hedis & Risk Adjustment
- Targeting local providers who would benefit from our Medical Risk Adjustment & HEDIS / STARS training
- Reaching out to physicians, medical groups, IPAs and hospitals, and building positive, consultative relationships
- Educating providers on how to improve their Risk Adjustment Factor (RAF) scores and Stars ratings, which measure their patients' health status
- Developing comprehensive, provider-specific plans to increase their RAF / STARS performance
- Training providers on our Risk Adjustment & STARS methods and tools, and working toward their compliance with our programs
- Collaborating with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts
- Conducts physician chart audits (including research and presentation)
Philadelphia, PA
Manager of Hedis & Risk Adjustment
Philadelphia, PA
Dach, Treutel and Kreiger
Philadelphia, PA
Manager of Hedis & Risk Adjustment
- Target local providers who would benefit from our Medical Risk Adjustment & HEDIS / STARS training
- Contact physicians, medical groups, IPAs and hospitals, and build positive, consultative relationships
- Educate providers on how to improve their Risk Adjustment Factor (RAF) scores and Stars ratings, which measure their patients' health status
- Develop comprehensive, provider-specific plans to increase their RAF / STARS performance
- Collaborate with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts
- Conducts onsite physician chart audits (including research and presentation) and identifies potential suspects through clinical documentation where diagnosis is clinically indicated but not documented
- Assess and interpret whether the coding assigned by the provider was properly assigned based upon review of the medical documentation and application of the coding guidelines
present
Dallas, TX
Director, Medicare Risk Adjustment
Dallas, TX
Tromp, Padberg and Walker
present
Dallas, TX
Director, Medicare Risk Adjustment
present
- Understand Humana’s market position within the region and remaining current with Medicare industry developments and the evolving regulatory environment
- AHIMA or AAPC (CPC) coding certification Healthcare Coding Practices
- Strategically creating policies and processes
- AHIMA or AAPC (CPC) coding certification; ICD-10 certification
- Assuring all regional MRA functions and Humana activities are in compliance with relevant CMS regulations
- Optimize business performance by coordinating with internal and corporate partners for all related business purposes
- Build and maintain a cohesive and talented team by establishing clear direction, goals and responsibilities
Education
Education
Bachelor’s Degree in Finance
Bachelor’s Degree in Finance
Kean University
Bachelor’s Degree in Finance
Skills
Skills
- Critical Thinking with strong organization skills along with detailed documentation proficiency
- Strong ability to work in matrix environment
- Ability to work at a detailed level and maintain / retain a “big picture” outlook of overall system design / functionality
- Excellent project management, organizational, and leadership skills
- Ability to effectively communicate with both business and technical staff, conveying complex ideas verbally and in writing
- Familiar with coding methods and guidelines (CPT, ICD, HCPCS, POS, DRG, Revenue)
- 2-4 years of healthcare technology/business analysis experience
- Extensive experience with MS Access and SQL
- Experience with a variety of claim platforms
15 Risk Adjustment resume templates
Read our complete resume writing guides
1
Manager, Medicare Risk Adjustment Resume Examples & Samples
- High school diploma or equivalent
- AHIMA or AAPC coding certification (CCS, CPC-I or CPC)
- Progressive experience working in a healthcare setting and Medicare Risk Adjustment environment
- Managed care experience
- Strong relationship building skills
2
Medicare Risk Adjustment Director Resume Examples & Samples
- Progressive experience working in a healthcare setting specifically within a Medicare Risk Adjustment or Risk Adjustment Factor organization/environment
- Demonstrated leadership skills and experience managing a team
- Experience working in a large matrixed organization
- Experience with putting policies and procedures in place while thinking strategically
- Experience setting new policies and procedures into practice specifically working with Risk Adjustment Factors and/or Healthcare coding practices
- Strategically creating policies and processes
- Experience managing a team onsite and remotely
- AHIMA or AAPC (CPC) coding certification Healthcare Coding Practices
- Experience Knowledge of Humana’s internal policies, procedures and systems
3
Director, Texas Medicare Risk Adjustment Resume Examples & Samples
- Develop comprehensive knowledge of Humana’s Medicare segment strategy and commitment to our Business Strategy - "The Integrated Care Delivery Model."
- Collaborate with the Texas region operations team (including Finance and Actuarial functions) and Corporate MRA group to align MRA activities and deliverables with CMS reporting, regulation and compliance requirements, including management of MRA scores, cost trends, product/benefit development and membership growth
- Provide leadership and direction for all MRA provider education and coding initiatives for the region, including strategies for educating provider groups on improving coding practices, coding accuracy and quality
- Develop strategic plans and objectives which support business strategy and P&L objectives
- Build a cohesive team by establishing clear direction, goals and responsibility; lead and develop staff through all phases from recruitment to training and advancement opportunities
- Cultivate internal and external business relationships which will serve as resources of technical knowledge and performance improvement
4
Medicare Risk Adjustment Frontline Leader Resume Examples & Samples
- Demonstrated emotional intelligence and confidentiality
- Ability to work independently under general instructions and with a team
- Proven Ability to build and maintain relationships internally & externally
- Associates working in Arizona must comply with the Tobacco Free Hiring Policy (see details under additional information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test
- Associate’s and/or Bachelor’s degree
- Current AAPC or AHIMA coding certification
- Health Plan background
5
Medicare Risk Adjustment Frontline Leader Resume Examples & Samples
- Proven ability to build and maintain relationships internally & externally
- Leadership experience preferred
- AAPC and/or AHIMA coding certification
6
Risk Adjustment Integrity Unit Manager Resume Examples & Samples
- Proven leadership skills
- Demonstrated success working in collaboration with multiple departments and disciplines
- Strong computer skills including MS Office desktop applications (Word, Excel, Access)
- Demonstrated competency in both oral and written communication skills
- Solid understanding of process / work flow concepts
- Prior fraud investigation experience (AHFI preferred)
- Prior experience with data and analytics
- Prior SQL experience
- Prior experience with Medicare Risk Adjustment
7
Medicare Risk Adjustment Resume Examples & Samples
- Review medical record information to identify all appropriate coding based on CMS HCC categories
- Develop and implement process and quality improvement initiatives in CA market
- Complete appropriate paperwork/documentation/system entry regarding claim/encounter information
- Provider support, education and training related to revenue optimization, quality of documentation, level of service and diagnosis coding consistent with established coding guidelines and standards
- Provide real time support and coordination with Primary Care Providers and Care Coordinators for MRA coding, HEDIS and STARS
- Perform compliance audits for designated providers/centers consistent with established audit protocol
- Coordinate with clinical leadership in the development of provider training plans and for active support in the training process
- Organize and schedule periodic training as indicated from audit results, denial and down coding trends, level of service reports, etc. and/or as requested by medical leadership or market leadership
- Monitor Coding changes to ensure that most current information is available
- Other duties as may be assigned
- Bachelor’s Degree or a minimum of 5 years of experience working in a health care system coding department
- Prior experience in a fast paced insurance or health care setting
- Prior medical coding experience
- Strong organization and process management skills
- Strong collaboration and relationship building skills
- Training and presentation experience
- Excellent written verbal and written communication skills
- Proficient with Microsoft Word, PowerPoint and Excel
- CPC or CCS-P Coding Certification
8
Medicare Risk Adjustment Resume Examples & Samples
- Bachelor’s Degree in Finance, Accounting, or a related field
- Comprehensive knowledge of all Microsoft Office applications, Access, and multi-dimensional databases
- Experience with forecasting and developing projections
- Adept with working with financial data, analysis and metrics
- Excellent collaboration and communication skills
- Experience with Essbase/Smartview and Oracle systems
- Experience with SQL Server and SAS
9
Risk Adjustment Manager Resume Examples & Samples
- Bachelor’s Degree in Business, Finance or a related field or in progress
- Proficiency in analyzing and interpreting financial trends
- Certified coder through AAPC or AHIMA
10
Director, Medicare Risk Adjustment Resume Examples & Samples
- Develop comprehensive knowledge of Humana’s Medicare segment strategy and commitment to our Business Strategy: The Integrated Care Delivery Model
- Collaborate with the region operations team (including Finance and Actuarial functions) and Corporate MRA group to align MRA activities and deliverables with CMS reporting, regulation and compliance requirements, including management of MRA scores, cost trends, product/benefit development and membership growth
- Develop and apply keen insight regarding the current Medicare health care regulatory environment and industry competition, and how the components of Humana's business model (i.e. strategy, finance, bid development and operations) interrelate to make Humana competitive in the marketplace
- Establish and maintain management and performance controls by identifying, tracking, measuring and analyzing data to highlight problems, prevent losses, contain costs and direct the development of process improvements
11
Manager, Medicare Risk Adjustment Resume Examples & Samples
- Progressive operational experience in a formal or informal leadership role, preferably with some tenure at a fortune 100 company
- Experience required in developing and enforcing operational policies and procedures
- Strong provider negotiation skills
- Strong presentation skills (written and verbal communication)
- Electronic medical record experience
- Deep knowledge of Medicare Risk Adjustment to include medical record chart parts required for risk adjustment coding
- Experience with chart scanners, thumb drives, and basic uploading from a desktop to a separate location
- Working knowledge of Excel, PowerPoint, Word and Outlook
- Prior experience in a health care or insurance setting highly desired
12
Manager of Submissions, Risk Adjustment Resume Examples & Samples
- Develops policies and procedures for system, application and related operational processes in order to ensure optimization and compliance with established standards and regulations internally at WellMed and externally with CMS or other regulating body
- Provides short range trouble shooting for day-to-day issues and ongoing maintenance with Risk Adjustment Submissions and Reconciliation applications and reporting
- Makes recommendations as needed to ensure reliability of the systems and finds innovative solutions if problems should occur
- Ensures that the risk adjustment diagnostic submissions to CMS and / or health plans or their intermediary occur timely and accurately; this includes additions and deletions where appropriate
- Provides claims / encounter data reconciliation between CMS and / or health plans or intermediary with business claims and coding detail to ensure accurate risk adjustment payments on behalf of provider groups
- Defines project scope and objectives based on business needs combined with a thorough understanding of enterprise business systems and industry requirements
- Performs a major role in the development and implementation of major systems. This role may interface with multiple business units such as accounting / finance, claims, operations, physician clinics, customer service, executive management, and sales and marketing
- Serves as an expert resource regarding the alignment of enterprise system strategies with the business goals and strategic drivers
- Applies knowledge of managed care operating environment and underlying systems data to all major production systems used for delivery of services to internal and external clients
- Develops and maintains strong relationships with both internal / externals customers at the senior management and executive level in order to influence project teams and gain consensus on the selection of the most viable solutions
- The position acts as a key team member to both IT and the business
- Uses strong critical thinking skills along with managed care, or physician office business knowledge to have insight and understanding of business concepts, tools and processes that are needed for making sound decisions in the contact of the company’s business
- Tracks progress and notifies management of issues that require escalation, and assumes responsibility for resolving or coordinating the resolution of system and process issues
- Develops and maintains project plans, and manages specific tasks to ensure project success
- Collaborates on and oversees various projects as assigned that are cross-functional in nature
- Performs all other related duties as assigned
- Bachelor’s degree in Finance, Business, Computer Science, Information Systems or related technical field required (Four additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
- 10+ years of experience in developing requirements and performing system analysis
- Experience with various system development lifecycles such as waterfall, and Agile methods
- 5+ years of experience in Health Care
- 3+ years of experience leading technical projects or teams
- Ability to communicate ideas and problem solutions
- Ability to effectively work with both internal and external clients
- Working knowledge of Medicare Risk Adjustment and processing of related diagnostic submissions to CMS
- Advanced degree in a related discipline
- Three or more years supervisory experience
- 5+ years of experience in one or more of the following areas: systems design, database programming experience, HL7 integration, X12 integration, EDI, practice management system implementation and support, EMR system implementation and support, Claim adjudication system implementation and support, Care Management system implementation and support
13
Manager, Hedis & Risk Adjustment Resume Examples & Samples
- Targeting local providers who would benefit from our Medical Risk Adjustment & HEDIS / STARS training
- Reaching out to physicians, medical groups, IPAs and hospitals, and building positive, consultative relationships
- Educating providers on how to improve their Risk Adjustment Factor (RAF) scores and Stars ratings, which measure their patients' health status
- Developing comprehensive, provider-specific plans to increase their RAF / STARS performance
- Training providers on our Risk Adjustment & STARS methods and tools, and working toward their compliance with our programs
- Collaborating with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts
- Conducts physician chart audits (including research and presentation)
- Assesses and interprets whether the coding assigned by the provider was properly assigned based upon review of the medical documentation and application of the coding guidelines
- Identify potential suspects through clinical documentation where diagnosis is clinically indicated but not documented; discuss findings with providers for validation
- Able to field any questions or concerns and provide solutions that will mirror management’s guidelines
- Implement education, and provide formal training to Client providers and staff as needed regarding coding compliance, documentation guidelines, HCC education and Medicare / Medicaid regulations by proactively providing solutions to meet the needs of the Client provider
- Enhance professional growth and development through in-service meetings, and educational programs
- Work independently and rely on professional discretion and judgment; as well as a professional representation of Client / Optum
- Utilize management for escalation purposes
- Available to assist other team members in coding, HCC opportunities, HEDIS / STARS and act as a resource to less experienced staff
- Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current HEDIS / ICD-10 CM knowledge
- Schedule audits and provide patient lists to practice managers to promote a smooth audit process
- Finalizing documentation and providing feedback to team members based on findings
- Performs related work and projects as required
- Must possess a CPC coding certification or will have it completed within next 90 days
- Must have an excellent understanding of medical terminology, disease process and anatomy and physiology, clinical diagnoses and what constitutes diagnosing a disease
- Complete Understanding of ICD-9 / ICD-10-CM diagnosis coding classification and guidelines
- Must have Computer skills (i.e. MS Office)
- Must have good Organizational skills
- Must have good Communication and Presentation skills
- Must be task oriented and able to meet designated deadlines, productivity standards and able to work independently
- Must have strong Interpersonal skills and excellent Customer Service skills
- Must be punctual and demonstrate a professional image wearing business attire
- Ability to travel locally to provider practices will be out in field 75% with rare overnight stay required
- Experience in face to face interaction with Providers and staff to correct coding and documentation quality (knows how to directly address issues without being confrontational)
- Knowledge of Risk Adjustment HCCs, HEDIS / STARS, network and contracting
14
Risk Adjustment Informatics Specialist Resume Examples & Samples
- Working knowledge of CMS STARS and Risk Adjustment programs. Must know HCC
- Working knowledge of Medicare Advantage & Pharm D operations and complex data requirements
- Experience with a variety of claim platforms
- Extensive experience with MS Access and SQL
- 2-4 years of healthcare technology/business analysis experience
- Familiar with coding methods and guidelines (CPT, ICD, HCPCS, POS, DRG, Revenue) a plus
- Ability to effectively communicate with both business and technical staff, conveying complex ideas verbally and in writing
- Ability to translate analytical business needs into high level and detailed functional requirements / specification document
- Ability to work at a detailed level and maintain / retain a “big picture” outlook of overall system design / functionality
- Critical Thinking with strong organization skills along with detailed documentation proficiency
- Strong ability to work in matrix environment
- Excellent project management, organizational, and leadership skills
15
Risk Adjustment Operational Lead Resume Examples & Samples
- Leads multiple cross-functional and vendor-solution focused risk adjustment initiatives
- Plan, develop, implement, and monitor Cigna's Risk Adjustment program
- Monitor key performance indicators and work jointly with leadership to report on influencing factors and evaluate trends
- Analyzes and measures the effectiveness of existing risk adjustment processes and collaborates with leadership to develop a sustainable, repeatable and quantifiable process for growth in additional markets
- Coordination and oversight of vendor solutions to ensure implementation and/or day-to-day solutions perform as designed
- Collaborate with RADV Leader to incorporate RADV findings into Risk Adjustment processes
- Participate with team in the development of risk adjustment optimization and risk mitigation models
- Work closely with Quality Leader to ensure Risk Adjustment activities adhere to Cigna Best Practices and CMS regulations
- Provide ongoing updates on risk adjustment activities to segment and executive leadership
- Establish ROI measurements analysis as needed to support activities and provide updates to segment controller monthly or as needed
- Ensures projects are completed within committed time and budget and are integrated with other business and related projects
- Bachelor’s degree highly preferred or equivalent relevant work experience
- Requires strong analytical and organizational skills
- Ability to deal with ambiguity and to turn plans into actions
- Familiarity with Medicare Risk Adjustment and STARS (quality program) highly preferable
- Knowledge of Quality Rating System (QRS) highly preferable
- Budgeting skills
- Ability to effectively motivate others
- Exceptional communication skills, including written and verbal (formal and informal)
- Demonstrated change agent skills within a matrix environment
- Proficient Microsoft Office skills related to Excel, PowerPoint and Word
16
Director, Medicare Risk Adjustment Resume Examples & Samples
- Provide leadership and direction for all functions related to MRA education and coding for the 2-state region (CO & NM)
- Facilitate decision-making with regional and corporate leadership based on strategic and tactical recommendations for program improvement
- Build and maintain a cohesive and talented team by establishing clear direction, goals and responsibilities
- Direct and manage all regionally-based risk adjustment activities
- Work cross-functionally to establish risk adjustment analytics such as predictive modeling for coding improvement opportunities, provider coding performance, risk score trending and tracking, and transfer payment accruals
- Optimize business performance by coordinating with internal and corporate partners for all related business purposes
- Work with the regional analytics team to identify and target providers for additional training on improving documentation, strengthening coding practices and ensuring coding accuracy
- Understand Humana’s market position within the region and remaining current with Medicare industry developments and the evolving regulatory environment
- Assuring all regional MRA functions and Humana activities are in compliance with relevant CMS regulations
- Progressive experience working in a healthcare setting, specifically within a Medicare Risk Adjustment organization or environment
- Demonstrated leadership skills and experience managing a team, particularly in a production type environment
- Strong internal and external relationship-building skills
- Experience with implementing policies and procedures while thinking strategically
- 3+ years of experience working in or with Risk Adjustment and / or HEDIS / Stars Quality programs
- Proficient in MS Office (including Excel Pivot tables and functions, PowerPoint and Word)
- 2+ years of experience working with common office software, coding software, and/or abstracting systems
- Master’s degree (preferably in Healthcare or relevant field)
- AHIMA or AAPC (CPC) coding certification; ICD-10 certification
- Contracting, Sales or Consulting experience
- Healthcare coding experience
- Experience working with mid or large-sized physician practices on Medicare STARS and/or HEDIS performance measures and metrics
17
Manager of Hedis & Risk Adjustment Resume Examples & Samples
- Target local providers who would benefit from our Medical Risk Adjustment & HEDIS / STARS training
- Contact physicians, medical groups, IPAs and hospitals, and build positive, consultative relationships
- Educate providers on how to improve their Risk Adjustment Factor (RAF) scores and Stars ratings, which measure their patients' health status
- Develop comprehensive, provider-specific plans to increase their RAF / STARS performance
- Train providers on our Risk Adjustment & STARS methods and tools, and implement coding education to providers as needed regarding coding compliance, documentation guidelines, HCC education and Medicare regulations by proactively providing solutions to meet the needs of the provider
- Collaborate with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts
- Conducts onsite physician chart audits (including research and presentation) and identifies potential suspects through clinical documentation where diagnosis is clinically indicated but not documented
- Assess and interpret whether the coding assigned by the provider was properly assigned based upon review of the medical documentation and application of the coding guidelines
- Rely upon independent judgment and decision making while at a provider site, whether conducting an audit or providing training/education, both from historical and / or real time data
- Maintain strictest confidentiality based on HIPPA privacy policy
- Provide feedback and present solutions regarding trends or patterns noticed in provider coding
- Reports to/works with the Director of Network Programs
- * This position will cover Charleston ***
- Must possess a minimum of a Vocational Degree with a focus on clinical i.e. LPN, RN, NP, PA
- Must have completed coding certification course, AAPC / AHIMA, or other accredited certifying body, or completed college courses with degree in coding or currently enrolled in program or possess 3 years diagnosis coding experience
- Previous consulting or sales experience
18
Medicare Risk Adjustment Director Resume Examples & Samples
- Provide leadership and direction for all functions related to MRA education and coding for the 4-state region (KS, MO, OK, AR)
- Develop strategies for educating provider groups on improving coding practices and coding accuracy
- Optimize business performance by coordinating with the internal department partners for all business purposes, and will provide leadership and direction for all MRA functions
- Understand Humana’s marketplace for this region industry and Medicaid regulatory environment assuring all MRA functions are in compliance with CMS regulations
- Develop strategies for educating provider groups on improving physician documentation, coding practices and coding accuracy
- Build a cohesive team by establishing clear direction, goals and responsibility
- Progressive experience working in a healthcare setting
- Knowledge of Medicare Risk Adjustment, preferred, not required
- Ability to think strategically and operationalize productive ideas
- Healthcare Coding Practices experience
- Knowledge of Humana’s internal policies, procedures and systems
19
Risk Adjustment Integrity Unit Manager Resume Examples & Samples
- Ensure team has appropriate staffing and skill sets to conduct investigations. Ability to expand team as necessary and provide new associate training
- Ensure team has appropriate access to resources, tools, and business areas necessary to accomplish objectives
- Develop and maintain key working relationships across Humana to ensure collaboration as necessary
- Ensure team operates in accordance with Humana and RAIU policies, processes, standards and procedures
- Ensure team members maintain appropriate credentials necessary to perform their job
- Manage team’s case load efficiently and effectively
- Ensure cases are investigated/reviewed in a timely manner
- Ability to work closely with the legal department and outside counsel as needed on confidential or high risk investigations
- Encourage growth and development among team members to support Humana’s goals and vision
- Minimum 2 years Medicare Risk Adjustment Auditing/Investigation Experience
- Strong understanding of risk models and risk contracts
- Successful track record in facilitating and managing projects and teams
- Ability to create legal documents/correspondence
- Experience in litigation prep
- Likes to focus on the “big picture” and thrives in a fast paced, multi-project work environment
- Strong organizational, interpersonal, and communication skills
- Computer literate ( MS Word, Power Point and Excel)
- Ability to handle multiple tasks and deadlines with attention to detail
- Self-starter with analytical thinking ability
- JD/MBA
- Experience leading people
- Familiarity with Humana’s various lines of business and productsReporting Relationships
20
Dir, Risk Adjustment Resume Examples & Samples
- Manages staff in division
- Sets training and coaching plan for Corporate and health plans on Risk Adjustment concepts and critical success factors
- Plans timelines and resource requirements; works with staff and Analytics to figure out dollars at risk
- Sets retrospective review policies
- Sets prospective review policies
- Sets RADV (proposed CMS audit) policies (emphasize compliance should be considered as well as revenue)
- Sets coding policies and plans long-term plan to use technology and other resources to provide more and better information to network providers
- Develops tracking and monitoring mechanisms for all projects
- Minimum of 5 year's experience in health plan encounter and chart data retrieval projects or equivalent
- 2 years Medicare experience
- 2 years Medicaid experience
- Medical coding experience
- Provider communication experience
21
Risk Adjustment Specialist Resume Examples & Samples
- Develops, implements, and manages all project plans related to initiatives to improve plan risk score performance
- Monitors performance and evaluate results of risk adjustment initiatives
- Manages relationships with external vendors assisting with risk adjustment initiatives
- Oversees accuracy and distribution of documentation and reports required by vendors and internal departments
- Works closely with Provider Services staff to outreach and educate the provider network on proper coding practices
- Ability to learn internal/external systems
- Innovative thinker and ability to independently implement ideas
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
- 1 - 3 years experience in Managed Care Programs, preferably Medicaid. Experience working with providers to effect change
22
Mgr, Risk Adjustment Resume Examples & Samples
- Manages staff in the risk adjustment division
- Implements coaching and training plans
- Sets policies related to risk adjustment
- Negotiates and maintains vendor contracts and relationship 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
- Escalate gaps in projects to Director or senior leadership
- Responsible for assisting the Director with implementation and oversight of risk adjustment and mechanism for projects
- 3 years experience working in Risk Adjustment in a healthcare environment
- Proficiency with risk adjustment methodologies
- Knowledge of change management
- 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
- 1 year management experience
- Experience with risk adjustment data validations or equivalent compliance audits
23
Supv, Risk Adjustment Resume Examples & Samples
- Supervises staff in the risk adjustment division
- Defines and documents work expectations for the team
- Distributes work and projects to staff and oversees completion by deadline
- Oversees chart chases with HEDIS, removes barriers, assigns resources to ensure high success rate
- Participates in risk adjustment meetings to discuss programs, issues, solutions and report status
- Reviews operational activities and risk score reports on a monthly basis to identify gaps and need for escalation
- Conducts weekly meetings with staff to check in on efforts, mobilizes resources and address issues as needed
- Oversees provider groups and vendors performance, identifies gaps that may impact risk scores or risk adjustment activities
- Conducts presentations at provider performance and join operation meetings
- Provides coaching and implements training
- Responsible for assisting management with implementtion and oversight of risk adjustment and mechanism for projects
- 3-4 years experience with Managed Care
- Experience working with providers to effect change
- 1 year+ supervisory experience
24
Specialist, Risk Adjustment Resume Examples & Samples
- Assist with implementation and monitoring local risk adjustment coordination efforts
- Assist with implementation of risk adjustment strategy in conjunction with Corporate Risk Adjustment department and plan QI and Provider Services Directors
- Removes barriers to access to provider records and / or barriers to contacting members
- Works with HP and Corp Reporting to monitor completed provider and member assessments to ensure Corporate goals are achieved within that HP
- May be asked to Upload HEDIS & RAMP files as directed by HEDIS & Risk Manager to File Net storage solution in a timely manner
- May be asked to Monitor and bring resolution to data mismatch and errors within FileNet
- Assists in current load of files as well as historical upload to FileNet
- Excellent influencing and negotiating skills
- 1 - 3 years experience in Managed Care or equivalent experience
25
Manager of Submissions, Risk Adjustment Resume Examples & Samples
- Provides short range trouble shooting for day-to-day issues and ongoing maintenance with Risk Adjustment Submissions and Reconciliation applications and reporting. Makes recommendations as needed to ensure reliability of the systems and finds innovative solutions if problems should occur
- Performs a major role in the development and implementation of major systems
- This role may interface with multiple business units such as accounting / finance, claims, operations, physician clinics, customer service, executive management, and sales and marketing
- Bachelor’s degree in Finance, Business, Computer Science, Information Systems or related technical field (Four additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
- Ten or more years of experience in developing requirements and performing system analysis
- Two or more years of experience in Health Care
- Three or more years of experience leading technical projects or teams
- Working knowledge of Medicare Risk Adjustment and / or Medical Claims processing
- Five or more years of experience in one or more of the following areas: systems design, database programming experience, HL7 integration, X12 integration, EDI, practice management system implementation and support, EMR system implementation and support, Claim adjudication system implementation and support, Care Management system implementation and support
26
Senior Specialist, Risk Adjustment Resume Examples & Samples
- Develops and manages implementation and monitors local risk adjustment coordination efforts
- Escalates problems promptly that would prevent Corporate goals from being achieved and recognizes the financial and compliance risk of not doing so
- Works with Manager, Coding and Education and Manager, Vendor Oversight and CMS Submission to implement appropriate chart reviews and in-home assessments
- Identifies, develops and implements provider/member programs specific to risk score improvement
- Assists with relationship building strategies and opportunities for financial growth through risk score improvement initiatives
- 3-4 years experience in Managed Care or equivalent experience
- Some Clinical training
27
Dir, Risk Adjustment Resume Examples & Samples
- Experience working in a Risk Adjustment division for a Health Plan in a Medicare, Medicaid and/or Market Place environment
- Extensive knowledge in Medicare, Medicaid and/or Market Place
- Very analytical with advanced knowledge of MS Excel; Knowledge of SQL helpful
- Experience in revenue cycle work helpful, not required
28
Risk Adjustment Informatics Specialist Resume Examples & Samples
- 2-4 years of healthcare technology/business analysis experience; must have healthcare experience
- Working knowledge of CMS STARS, Risk Adjustment programs and HCC strongly preferred
- Working knowledge of Medicare Advantage & Pharm D operations and complex data requirements; preferred
- Strong analytical and interpersonal skills required
29
Risk Adjustment Resume Examples & Samples
- Validate RxHCC risk adjustment extract logic, which includes oversight of logic programmed within internal systems based on CMS rules and guidelines
- Monitor CMS changes to the RxHCC risk adjustment process and calculate any corresponding impacts
- Provides short range trouble shooting for day to day issues and ongoing maintenance with the RxHCC risk adjustment applications and reporting. Makes recommendations as needed to ensure reliability of the process and finds innovative solutions if problems should occur
- Provides encounter data reconciliation between CMS and health plan claims detail to ensure accurate RxHCC risk adjustment payments
- Ensures that the CMS return files received either directly from CMS or from the health plan or their intermediary are reconciled to the submitted files
- Develops policies and procedures for system, application and related operational processes in order to ensure optimization and compliance with CMS RxHCC risk adjustment guidelines
- Maintains RxHCC risk adjustment data base for complex analytics
- Analyze, review, forecast, and trend complex data
- Review the analysis and interpretation of others work
- Present analysis and interpretation for operational and business review and planning
- Develop ad-hoc and standard operational reports
- Support short and long term operational/strategic business activities through analysis
- Develop and implement effective/strategic business solutions through research and analysis of data and business processes
- Document/Communicate root causes affecting performance as identified through analysis
- Determine and track financials implications of initiatives
- Document/communicate key milestones for effective strategy execution
- Bachelor degree in Business Administration, Finance, Health Administration or related field
- 3+ years of healthcare data analysis experience in a healthcare plan or environment, preferably in Medicare
- Intermediate to Advanced SAS and SQL programming skills
- Knowledge of ETL processes
- Intermediate to advanced MS Excel
- Proficiency with MS Access
- Ability to identify underlying causes and potential mitigation strategies for medical cost trends, based on broad knowledge of healthcare issues
- Proven ability to use large datasets to produce high quality analysis and metrics
- Proven ability to perform statistical analyses to independently identify root causes of medical cost trends
- 3+ years of healthcare data analysis experience in a Medicare healthcare plan
- Advanced MS Excel
- Intermediate MS Access
- Advance SAS and SQL programming skills
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Senior Specialist, Risk Adjustment Resume Examples & Samples
- Helps support day to day operations
- Helps under supervision to support Risk Adjustment related projects, including goals, objectives, milestones and deliverables
- Identifies opportunity for improvement and minimize data gaps
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
- Provides support and assist in developing strategies, tracking program results and progress, developing procedures and policies for risk adjustment efforts
- 0-1 year experience in Managed Care
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Mgr, Risk Adjustment Resume Examples & Samples
- Manages the implementing of Risk Adjustment Management Programs related to complete capture of HCC Diagnosis codes, appropriate documentation of conditions based on claim record and/or member’s medical record. Programs manage by the project manager include, but are not limited to, training and educational activities and coordination of random targeted documentation audits and concurrent follow up feedback
- Manages the development and administering of an effective Risk Adjustment Management Program that assure risk scores of Molina membership accurately reflect their clinical health status. Program will include appropriate prospective and retrospective activities as well as a proactive Risk Adjustment Data Validation component
- Vendor Management of clinician chart audit activities, data mining patient lists, coordinating chart provisions with reviewers, communicating results to rendering physicians and tracking and analyzing findings
- Interfaces between Director of Analytics, Finance, Claims and Encounters, and RAMP team to successfully manage risk adjustment programs
- Conduct meetings and disseminates communication related to risk adjustment activities to senior leadership, Medicare operational leadership, RAMP Department, and provider physician/groups as necessary
- Maintains documentation of operational processes and ensures appropriate updates are done to existing policies and procedures as it relates to RAMP Department
- Conducts risk adjustment educational session with internal Molina stakeholders and external clients as it relates to the Risk Adjustment Management Programs
- Manage HCC Coding Accuracy at various levels of detail (e.g. by state, by product, by demographic segmentations)
- Resolve and track escalated physician issues related to risk adjustment program activities
- Participate as a team player by demonstrating support to peers, management and the department’s goals
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Manager Medicare Risk Adjustment Resume Examples & Samples
- Required Bachelor’s Degree in a work-related field/discipline from an accredited college or university required. Degree and accreditation in Health Information Management preferred
- Required 5-10 years progressively responsible and directly related work experience required, including a minimum of 5 years managing direct reports
- Required experience with Medicare Encounter Data Processing. Understanding of the 837 version 5010 EDI transaction format
- Required proven success with project management and/or program management in a matrix organization
- Required familiarity with health insurance coding conventions, particularly ICD-10
- Required to work onsite. Position located in Philadelphia, PA
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Director of Risk Adjustment Resume Examples & Samples
- Provide strong leadership for key CDQI initiatives
- Function as the business / process subject matter expert for risk adjustment and partner with other departments to develop and optimize risk adjustment tools and processes with a strong focus on continuous improvement
- Assure ideal market operations for CDQI to ensure projects are completed timely in accordance with company objectives
- Act as a primary liaison with new markets including cooperative development of transition plans for all affected entities to Care Delivery
- Monitor and track actual versus expected performance to target areas for improvement
- Analyze, identify root cause, and support remediation if needed for projects and areas of focus within CDQI
- Consult and provide input to the operations and project management teams
- Recommend areas of opportunities to the team in terms of process improvement
- Drive compliance with all applicable local, state and federal laws
- Strive to improve operational efficiencies and make recommendations as appropriate; take ownership of process as assigned and provide constructive information to minimize problems and increase provider and market satisfaction
- Partner with Local Care Delivery leadership teams and OptumCare management across markets to coordinate execution and implementation in all markets
- 3+ years of experience with Medicare Advantage Programs
- 10+ years of combined experience in a combination of the following areas: managed care, health insurance industry, government relations, network management, process improvement, legal / compliance, risk adjustment and practice management
- 3+ years of operational knowledge related to health insurance
- 3+ years of risk adjustment experience with expertise in one or more lines of business and / or risk adjustment functional areas; Retrospective Chart Review and / or Prospective In-Year Documentation programs and / or In-Home Assessment and / or Provider Education and / or Member Engagement
- 3+ years of experience in effectively reporting data, analyzing facts and exercising sound judgment when making recommendations to members of the Senior Leadership Team
- Intermediate level of knowledge of CMS submission requirements
- Understand and be familiar with RADV audit processes
- Inherent understanding of Fee-for-Service and Capitation arrangements
- Experience working with multiple levels and departments organizationally to accomplish defined objectives
- Proven track record in managing major projects and/or programs
- Ability to lead a complex or multifunctional / multi - location team / organization
- Proficiency with Microsoft Word, Excel, PowerPoint
- Specific program experience with Medicare Advantage Star Ratings and HEDIS
- Familiarity with Physician Practice Management or IPA Operations
- Experience in Medicare ACO Programs, MACRA, MIPS & APM’s
- Experience with Medicaid quality and risk adjustment programs
- Proven experience managing organizational growth and change
- Familiarity with Lean and / or Six Sigma
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Medicare Risk Adjustment Manager Resume Examples & Samples
- 2+ years demonstrated experience with Medicare Advantage risk adjustment
- 2+ years’ experience in health insurance
- Experience working with vendors
- Proficient in Word, Excel and PowerPoint
- Working knowledge of Medicare Advantage and Part D laws and regulations
- Familiarity with ICD-10
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