Fallon Health

  • Senior Leader Risk Adjustment - Managed Care Revenue - Growing Health Org!

    Location US-MA-Worcester
    Posted Date 5 months ago(1/17/2018 10:13 AM)
    Job ID
    # Positions
  • Overview

    This job description refernces Director but we would still love to hear from you if at a Senior Director or VP level. 


    The Director of Risk Adjustment will be responsible for setting the strategic direction for the revenue accuracy and risk adjustment efforts for all lines of business with risk adjustment (merged market commercial, Medicare Advantage, SCO, PACE, and Medicaid).


    Work to enhance our relationships with providers and members to enable these risk optimization efforts.   Support activities to access electronic medical records efficiently and effectively.


    The position will encourage optimized provider coding through training, reporting, and engagement efforts. Oversee vendor relationships with regards to chart review and in-home assessments for our members.


    Work internally to align quality metrics & risk optimization opportunities. Support targeting members for PCP visits and member enrollment efforts.


    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


    Provider Optimization Efforts (40%)

    • Support provider training on proper coding. Establish and/or foster and grow effective working relationships with providers.
    • Assess and recommend provider reporting to support optimization efforts
    • Work with risk providers on targeting members for visits and other optimization efforts
    • Support risk optimization efforts through the JOC process with providers
    • Provide relevant assumptions and details to assist in financial modeling
    • Support growth activities as needed

    Member Engagement and Optimization Efforts (40%)

    • Oversee vendor relationship(s) for in-home assessments and chart reviews
    • Ensures regulatory compliance is meet for in-home assessments
    • Assess the vendor performance at least once a year
    • Support targeting members for PCP visits and other member enrollment efforts (new member processes, health risk assessment activities)
    • Work to accurately assess ROI from member engagement activities

    Alignment of activities between risk adjustment and clinical quality activities (20%)

    • Act as a liaison between risk adjustment and the clinical teams to align activities, promote objectives, and reduce duplication of efforts
    • Align quality metrics and risk optimization efforts
    • Ensure accurate and appropriate P&Ps are in place and in compliance with CMS and other regulatory guidelines


    • BA or BS
    • 7+ years of managed care experience.
    • Solid knowledge of the industry and cross–functional work experiences in the areas health insurance finance, medical economics, actuarial, underwriting, and/or risk adjustment.
    • Excellent interpersonal, communication, presentation, and analytical skills.



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