Category: Uncategorized

 
 

Position:

Quality and Risk Adjustment Manager

Position Summary:

The Quality and Risk Adjustment Manager, PHSO, is the subject matter expert and lead in developing and facilitating the implementation of new and existing healthcare Quality and Risk Adjustment strategies for a PHSO client. This position advises the client on quality and risk adjustment initiatives and provides support for program planning, patient campaigns, outreach tactics, and educational programs; conducts data collection; and reports and monitors key performance measurement activities for both quality and risk adjustment.

Job Description:

Primary Responsibilities

• Manage a comprehensive and coordinated Quality and Risk Adjustment strategy for our PHSO client by: developing data mining strategies; facilitating collection methodology and an effective quality and risk adjustment program; standardizing gap closure workflows and strategies; providing support for patient campaigns, and facilitating the development and implementation of Quality and Risk Adjustment programs for internal and external PHSO clients.
  
• Develop and maintain effective internal and external relationships through effective and timely communication.
  
• Synthesize and organize data, present information, and provide executive summary of material.
  
• Take initiative and action to respond, resolve and follow up regarding quality and risk adjustment with internal and external customers in a timely manner with outstanding customer service.
  
• Develop and maintain an expert level of knowledge of PHSO Quality metrics (such as MSSP, HEDIS, MA 5-Star, NQF) and MA, ACA, and Medicaid risk-based reimbursement methodologies.
  
• Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
  
• Oversee and improve the various quality and risk adjustment processes.
  
• Assist client with development of a comprehensive Risk Adjustment and Quality strategy and work plan, including workflow, outcome measures and performance evaluation.
  
• Facilitate the development of key quality and risk adjustment key performance indicators.
  
• Present quality performance results and findings regularly, including the overall measure performance, improvement strategies and tactics.
  
• Serve as a quality and risk adjustment subject matter expert for internal and external clients.
  
• Support activities of the PCV (Preventative Care Visit), patient outreach, and physician educational campaigns.
  
• Perform other duties as assigned.
  

Qualifications

• Bachelor’s degree; BSN, LPN, RHIA preferred
  
• 5+ years of experience in Quality Management and experience in HEDIS, MIPS/MSSP, and MA 5-Star, preferably in a health system or clinic setting
  
• 3+ years demonstrated management and team development skills
  
• 3+ years’ experience and proven success managing, implementing and auditing clinical quality programs
  
• 3+ years’ experience within healthcare, health plan, or health system, including payer, hospitals, Medicare/Medicaid, provider environment, or managed care
  
• Knowledge of Risk Adjustment Payment methodologies; understanding of CMS HCC, HHC, and Medicaid
  
• Medicare Advantage knowledge strongly preferred
  
• Proficiency with clinical data management and statistical quality tools
  
• Analytical and quantitative problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  
• Ability to operate in a fast-paced and dynamic environment
  
• Excellent verbal, written, and interpersonal communication skills; ability to present in front of a group
  
• Excellent organizational capabilities with ability to work effectively as a team player
  
• Strong aptitude for critical thinking and demonstrated data skills
  
• Capable of meeting deadlines and executing projects with minimal supervision
  
• Willingness to acquire new knowledge from an unfamiliar domain
  
• Ability to manage multiple job functions, priorities, and deadlines under pressure with shifting priorities in an expedient and decisive manner
  
• Ability to collaborate and work with all professional levels, internally and externally
  
• Detail oriented
  
• Proficiency in Microsoft Office Programs including Word, PowerPoint, Excel, and Outlook
  

Working Conditions

• While performing the duties of this job, the employee works in normal office working conditions.
  

Disclaimer

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
  

Lumeris is an EEO/AA employer M/F/V/D.

Location:

Remote – MO

Time Type:

Full time

 
 

From <https://lumeris.wd1.myworkdayjobs.com/en-US/LC/job/Remote—MO/Quality-and-Risk-Adjustment-Manager_R0004035?mode=job&iis=Indeed.com&iisn=Indeed.com>

*Please Note: This position is open until filled. Application assessment will be ongoing and the hiring authority reserves the right to offer the position at any time during the recruitment process. It is to the applicant’s advantage to apply as early as possible. *

 
 

The ideal candidate for this position will have program management and/or consultative experience in health services, social services or Medicaid programs. 

 
 

Position Objective:

This position participates in the design and development of programs and contracts, and the daily oversight and management of them. This includes policy promulgation, developing strategic recommendations, contract development and federal negotiations for Cost Allocation Plan (CAP) design and implementation; program and contract monitoring, developing and maintaining program guidance, developing manuals and training materials, developing and conducting program training and presentations, and providing technical assistance. This position may assist other program managers in completing these or other activities.

 
 

This position is responsible for participating in management of the Washington State Courts Juvenile Service Divisions (WSCJSD) Medicaid Administrative Claiming (MAC) program. MAC programs are a state-federal partnership which provider reimbursement to government contractors for the time they spend supporting the Medicaid State Plan. MAC programs are authorized through a federally approved CAP which describes the program and the methodology used to determine eligible reimbursements. This position supports other MAC programs in the unit, as well as reimbursement contracts with state agencies. This position may be assigned and be directly responsible for specific components of these programs.

 
 

Some of what you will do:

• Responsible for using independent judgment and program subject matter expertise and knowledge to develop, write, and oversee all aspects of assigned MAC programs and reimbursement contracts including business requirements, policy promulgation, contract and CAP development, contract execution, claiming processes, program and contract monitoring, claim payment, writing and maintaining  program manuals, training materials, and developing provider and stakeholder training to ensure the HCA’s MAC time study and claiming processes are in compliance with federal guidelines.
  
• Demonstrate extensive knowledge and understanding of applicable state and federal rules and regulations; consults with the Centers for Medicare & Medicaid Services (CMS) as required.  Utilize expert analysis of new and emerging federal and state regulations to determine the impact or need to make changes to assigned MAC programs.
  
• Provide professional and technical subject matter expertise and guidance for developing, writing, implementing, and overseeing policies and procedures having statewide impact on assigned MAC programs and reimbursement contracts.
  
• Responsible for independent judgment and program subject matter expertise to provide professional and technical expertise and guidance, consultation and recommendations for the design, development, testing and use of the numerous processes, and methods involved in the time study, claim calculations, and other aspects of MAC programs and reimbursement contracts.
  
• Designing, developing, writing, implementing, evaluating and improving monitoring tools and processes.
  
• Represent HCA and the state in negotiations with state and federal partners on major, substantive, and innovative MAC program methods and related federal law impacting HCA.
  
• Provide related MAC program and time study system training to external stakeholders, internal managers and work units as needed.
  
• Plan, design, develop, write, schedule, test, implement, evaluate and improve program policy and procedures for assigned MAC program business requirements and operational processes.
  
• Plan, design, develop, write, schedule, implement, evaluate and improve on-going training relating to program modifications needed to ensure assigned MAC programs are in compliance with federal guidelines.
  

 
 

Here is what we are looking for (Required Qualifications):

A Master’s degree with major study in public health, public administration, social work, or closely related field and two years of supervisory or consultative experience in health services, social services or Medicaid programs.

(Two additional years of qualifying experience will substitute for the required Master’s degree provided a Bachelor’s degree has been achieved)   

OR

A Bachelor’s degree and two years of experience administrating one or more statewide policies or programs of an agency or agency subdivision. 

OR

Additional qualifying experience may substitute year for year, for required education.

 
 

Desirable/Preferred Qualifications:

Communicate and work effectively with a broad range of program and fiscal managers and staff, contractors, and their agents, legislators and legislative staff, and other stakeholders.

 
 

Highly capable of working in multiple environments such as remotely and in office.

 
 

Highly capable of mastering virtual platforms and utilizing multiple different platforms on a daily basis.

 
 

Coordinate and track multiple, diverse activities and work independently with limited supervision.

 
 

Strong ability to complete assignments with limited or ambiguous guidance.

 
 

Make clear, understandable written, graphic and verbal directions.

 
 

Highly independent, self learner, with ability to easily transition between group and independent assignments.

 
 

Make presentations consisting of cost/benefit, process improvement and similar analyses and policy recommendations; capable of learning new analytics tools.

 
 

Envision and develop timely program plans and monitoring of results.

 
 

Write clear and concise reports.

 
 

About the HCA: 

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

 
 

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, and the School Employees Benefits Board (SEBB) Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

 
 

What we have to offer:

• Meaningful work with friendly co-workers who care about those we serve Voices of HCA 
  
• A clear agency mission that drives our work and is person-centered HCA’s Mission, Vision & Values
  
• A healthy work/life balance, including alternative/flexible schedules and mobile work options.
  
• Infants in the workplace Infants at the Workplace Video
  
• A great total compensation and benefit package WA State Government Benefits
  
• A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby. 
  
• Tuition Reimbursement
  
• And free parking! 
  

 
 

About Olympia and Washington State:

Washington State offers a total work/life package of pay, benefits, flexibility, and workplace opportunities to help you get the most out of your career and out of life. Washington State is a great place to work, play, and be a part of a community, offering quality of life that is unsurpassed. From the high energy urban center of Seattle, one of the nation’s top ranked cities, to the more relaxed pace of our rural communities, Washington’s distinctive Northwest lifestyle blends a progressive, creative culture with a casual nature.

 
 

How to Apply: 

 Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered.  Failure to follow the application instructions below may lead to disqualification.  To apply for this position you will need to complete your profile and attach:

• A cover letter that specifically addresses how you meet the qualifications for this position. 
  
• Current resume 
  
• Three professional references
  

 
 

 Washington State is an equal opportunity employer. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may call the Human Resources Office at 360.725.1761 or email Dennis.Lienemann@hca.wa.gov.

 
 

 *Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant’s suitability and competence to perform in the position. *

 
 

From <https://www.governmentjobs.com/careers/washington/jobs/2931459/medicaid-program-manager-maps2-mpoi>