Risk Adjustment Manager

Description

Manages the risk adjustment initiatives for the organization, including in-home health assessments, embedded NP, medical chart retrieval, HCC risk adjustment data & documentation integrity, and supporting vendor programs. Oversees implementation of programs designed to ensure all diagnosed codes and conditions are properly supported by appropriate documentation in patient chart. Programs include but are not limited to training and educational activities, Nurse Practitioner and AWV programs, clinical chart review programs, retrospective reviews, encounter submission, data reconciliation, and electronic data submission including supplemental data submissions

What You'll Do

• Oversees daily regional operations of the coding and specialists’ team, retrospective and prospective review teams and programs and ensures the appropriate strategy, tactics and data capture processes are in place.
• Collaborate closely with providers and regional network leadership teams to implement risk adjustment education, processes, and programs effectively for accurate and compliant capture of members' conditions.
• Identify and analyze implications of key changes to the regulatory & policy environment on provider organizations in the areas of risk adjustment and compliance.
• Serves as the vendor(Chart review / AWV / Cozeva etc) and provider liaison to ensure coordination of efforts, effective relationship management, cost effectiveness, delivery of work product, quality of work, delivery of required training for internal associates and timely communication on all issues.
• Manage the regional employed NP program and the vendor driven AWV program
• Audits the chart review outcomes provided by the risk adjustment vendor and audits provider coding trends to identify potential gaps.
• Support effective business relationships with external entities, including payers and health plan partners with continuous focus on performance improvement related to population clinical quality and patient experience goals.
• Requires significant collaboration with internal stakeholders including, but not limited to, primary care section and specialty service lines, IT, business services and finance, contracting, compliance, as well as external entities and vendors will be required
• Manage regional Provider Incentive and Member Incentive Programs
• Recover dx codes from institutional encounters through hospitalists / encounters
• Roll out new regional programs as applicable to improve documentation and accurate coding
• Ensure the accuracy of risk data in and out of core systems
• Establish EMR connectivity with Astrana Health and provider group / IPA
• Ensure compliance with all applicable regulatory and accreditation guidelines such as CMS, NCQA, DMHC etc.
• Develop policy and procedures as required for departmental improvements.
• Complete special projects when required.

Skills, Knowledge & Expertise

demonstrated ability and willingness to learn new software.

Environmental Job Requirements and Working Conditions

Work hours : Monday through Friday, standard business hours

Work schedule : You will be required to work onsite about two days per week at one of our corporate offices in Orange, Monterey Park, or Alhambra. You will be traveling to provider offices in Orange County approximately 10% of the time.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.

Additional Information :

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Astrana Health (NASDAQ : ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.

Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.