About the position
As a Medicare Risk Program Manager, you will be responsible for the development and maintenance of robust Medicare Risk Adjustment programs to ensure the health plan fully understands the illness burden of our membership. In this critical individual contributor role, you will manage risk adjustment programs, support the strategy execution and analyze risk adjustment program performance data to identify, lead and prioritize strategies to improve risk scoring accuracy in alignment with Wellmark strategies. As a driver of Medicare Advantage (MA) company-identified initiatives, you will be the point-person for driving success on coding accuracy and risk adjustment programs. You won't do it alone. In this role, you will partner alongside Wellmark, and joint venture, team members focused on program management, analytics, provider performance, and more to drive change and progress.
Responsibilities
- Develop and maintain a Risk Adjustment work-plan and convene committees and workgroups as needed.
- Responsible for implementation and oversight of risk adjustment related initiatives and projects.
- Partner with internal teams and associated external vendor partners to monitor program and vendor performance, facilitate oversight and performance improvement activities as needed.
- Collaborate with internal and external teams to ensure complete and accurate reporting of risk adjustment data in accordance with Centers for Medicare and Medicaid Services (CMS) requirements.
- Analyze risk program performance data to identify and prioritize strategies to help achieve risk adjustment program objectives.
- Coordinate and develop indicators related to risk adjustment operations to inform leadership on progress of activities and risk adjustment programs.
- Partner with internal stakeholders and/or external vendors in the definition, design, implementation, and maintenance of data files and data extracts to meet reporting needs of Wellmark's coding accuracy initiatives.
- Apply and maintain knowledge of applicable current and proposed laws, regulations, and CMS guidance applicable to risk adjustment specifically, and general knowledge of Medicare Advantage and ACA/Exchange based requirements.
- Collaborate with Medicare Advantage Network Performance team in support of delivering provider education to facilitate clinical documentation improvement and improve provider performance and outcomes.
- Other duties as assigned.
Requirements
- Bachelor's degree or direct and applicable work experience.
- 4+ years of related healthcare industry experience.
- Experience in the development & management of healthcare-related programs, which includes leading projects from ideation through execution and working in a highly matrixed environment with both internal and external partners.
- Knowledge of CMS rules and requirements of Medicare Advantage Health Plans.
- Demonstrated ability to think strategically to ensure program success.
- Demonstrated experience influencing stakeholders.
- Excellent analytical skills, data management capabilities, and strong attention to detail.
- Technical aptitude to learn new data management and analysis tools or methodologies quickly.
- Strong analytical, problem solving, and critical and strategic thinking skills.
- Strong written and verbal communications skills with the ability to share technical insights and recommendations with varying stakeholder audiences.
- Self-starter motivated by the opportunity to work in fast-paced environments and driven by measurable outcomes.
- Strong organization, time management, and prioritization skills.
- Collaborative approach to work with and ability to partner with different business areas.
- Proficiency with the Microsoft Office Suite.
Nice-to-haves
- 2+ years of experience in managing Medicare Advantage Risk Adjustment programs.
- Knowledge of industry standard ICD-10-CM and CPT coding principles.
- Certified Risk Adjustment Coder (CRC).
