About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose: 

The Senior Director of Risk Adjustment is responsible for the execution and oversight of risk adjustment services for Fallon Health government and state sponsored products including Medicare Advantage, Commercial/ACA, PACE, and Medicaid. 

Primary Job Responsibiities (Include duties that represent 5% or more of employee's time)

With demonstrated and proven success in government & state sponsored risk adjustment program operations, the Senior Director of Risk Adjustment Solutions will provide Fallon Health with leadership and expertise to execute on all of the following areas:

• End-to-end risk adjustment operations, program, and data mapping/integration.
• Risk adjustment vendor selection, implementation, and quality oversight.
• Retrospective and prospective program design, implementation, and oversight.
• Encounter data reconciliation opportunity analysis for RAPS/EDS, EDGE, Massachusetts Medicaid, and New York State MLTC.
• Design and oversight of Hierarchical Condition Category (HCC)/clinical documentation operations, quality oversight, education, and analytics.
• Provide feedback on revenue projections and forecasting for all risk adjustment lines of business.
• Comprehensive program integration to align with corporate initiatives to drive quality improvement and medical trend management.
• Comprehensive provider education and engagement strategies.
• Risk Adjustment Data Validation (RADV) and overpayment recovery mitigation and preparedness strategies.
• Federal and regulatory policies and procedures related to risk adjustment.

The Senior Director of Risk Adjustment solutions will be responsible for complex analysis, assessment, recommendation and implementation of risk adjustment programs for the following purposes:

• Financial Reporting and Projections - Projected impact of CMS rates and risk scores for budgets, forecasts, benefit design, and bid development. Trending and seasonality studies of risk adjusted revenues.
• Healthcare Economics - Population and provider segmentation for additional support and integration for health management teams, leveraging analytics to improve quality outcomes and manage medical expense trends.
• General Risk Adjustment Program Audit, Design, and Implementation - Identifying opportunities for provider and member interventions to improve early detection and accurate reporting of chronic disease (including assessment of vendor management and performance models).
• Policy and Regulatory Compliance - Advise senior leadership of economic impact of various policy considerations by government agencies related to risk adjusted models.

In addition to the responsibilities listed above, the Senior Director of Risk Adjustment Solutions will be responsible for designing, launching, managing, and overseeing operational delivery coupled with recommended opportunities for improvement within the following categories for risk adjustment:

• • Optimizing Revenue Strategies
  • Maximizing Analytics
  • Reducing Audit and Financial Risk
  • Closing Data Gaps
  • Responding to Regulatory Changes
  • Driving Performance Outcomes

Experience:

• 7-10+ years’ experience in the risk adjustment and Medicare managed care environment
• Understanding of applicable CMS Medicare Part C & D reporting requirements including manuals, review guides, and Code of Federal Regulations
• Ability to interact with internal and external customers at all management levels
• Project management and/or consulting experience a plus
• Strong problem-solving ability and a customer-centric focus
• Team focused
• Highly organized with a strong attention to detail
• Demonstrated leadership and management skills
• Effective collaboration skills and experience
• Adept in working across a heavily-matrixed organization
• Microsoft Office proficiency
• Strong oral and written communication skills, including presentation skills

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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