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Director of Risk Management - Managed Care

Company: MetroPlus Health Plan
Location: Hartford
Posted on: May 5, 2021

Job Description:

Job Description About NYC Health + Hospitals MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. Position Overview This is a new and evolving position within the plan where we are seeking to maximize our efficiency as it pertains to risk. Responsible for the implementation, oversight and ongoing execution of risk related activities as it pertains to both Federal and State risk models across various products offered by the plan. This position will manage risk processes and will work alongside a range of business units to ensure that the plan's populations are accurately represented via the applicable risk program and work towards addressing any obstacles. Responsible for collaborating with our network for education and support of appropriate coding down to the individual practice level. Plans, actions and progress to be reported at various levels including executive staff. Job Description * Individual will own the spectrum of risk activities such as managing workplans and activities across the plan. * Oversee day-to-day operational needs pertaining to encounter submission and risk adjustment activities (file transfers, error reporting, issue resolution). * Devise and implement strategies related to risk as it pertains to the methodologies in practice by NY State (CRG), Medicare (HCC) and ACA (HCC) products. * Incorporate best practices to optimize risk scores and develop reporting dashboards and KPIs to ensure appropriate oversight and visibility. * Work amongst various departments to identify, document and enhance existing processes that impact risk. * Assess and build initiatives specific to the needs/gaps found in our provider network as it pertains to appropriate coding practices. * Manage and engage multiple vendors/contracts who provide risk services, ensuring their support and effective outcomes. * Participates in the selection of appropriate risk vendor(s)/service(s) as needed. * Continuously support reporting and progress to both internal staff, including executives, as well as external providers. * Responsible for the timely and accurate submission of risk data via the NYS APD submission, ACA EDGE submission and CMS RAPS/EDPS submission processes * Provides support for any audits internal or otherwise (eg. RADV, Article 44) as it pertains to risk. * Create and operationalize policies and procedures for risk. * Ad-hoc reporting and support tasks. Minimum Qualifications * Bachelor's Degree required. Master's Degree preferred. * 5-8 years' experience in risk adjustment as a business analyst or other role. * Experience with the various risk methodologies from NY State and Federal programs. * Eagerness to learn, develop and own new processes from the ground up. * Knowledge of regulatory and submission requirements for each risk program (APD, EDGE, EPDS/RAPS). * Ability to build custom strategies based on experience and knowledge. * Strong communications skills. Professional Competencies * Integrity and Trust * Customer Focus * Functional/Technical skills * Written/Oral Communication

Keywords: MetroPlus Health Plan, Hartford , Director of Risk Management - Managed Care, Executive , Hartford, Connecticut

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