Director of Risk and Quality
Hello, we’re Belong.
We partner with regional payers to deliver Medicare Advantage and Special Needs Plan products.
With a dual focus on data-driven, proactive clinical intervention and unwaveringly empathetic patient experience, Belong has completely reimagined health insurance for seniors and other Medicare-eligible individuals who have been disregarded and deprioritized for far too long.
We believe that only by recognizing individuals can we make communities strong.
Belong Health. Kinder, more supportive care.
We are seeking an experienced and strategic Director of Risk and Quality to lead and scale our risk adjustment and Medicare quality programs. This individual will oversee all aspects of risk adjustment operations, including risk coding/documentation strategy, physician education, and vendor management as well as all aspects of quality improvement operations focused on HEDIS/STARs and inclusive of performance monitoring, gap closure efforts, and close partnership with physician partners to drive quality performance. The ideal candidate will bring deep Medicare risk adjustment and quality expertise, hands-on experience coordinating risk adjustment and quality improvement programs with physicians and primary care practice staff, and the leadership skills to collaborate cross-functionally and drive continuous improvement.
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES
- Lead the enhancement and operational management of comprehensive risk adjustment strategies (prospective, retrospective, and concurrent) for Medicare Advantage, ACO, and other value-based models.
- Lead the design and management of HEDIS and STARs strategies involving managing performance and driving operations through partnership with clinical teams, physician partners, and health plan partners.
- Define and establish standards and frameworks for Risk Adjustment and Quality related to KPIs, goals, and, action plans.
- Own risk and quality data accuracy and improvement initiatives across the enterprise.
- Oversee relationships and performance of external vendors, including chart retrieval and review, physician education, and coding partners.
- Collaborate closely with clinical leadership, analytics, operations, and the provider engagement team to align risk and quality efforts with team operations.
- Partner with analytics and data engineering teams to ensure the integrity of risk adjustment data feeds and reporting systems.
- Review risk adjustment reporting and performance to guide continuous improvement
- Guide provider engagement strategies in collaboration with the provider relations and education teams to ensure accurate and complete documentation and coding.
- Ensure compliance with CMS guidelines and audit-readiness of all risk adjustment programs.
- Stay up to date on regulatory changes, industry best practices, and innovations in risk adjustment and coding.
REQUIRED EXPERIENCE AND QUALIFICATIONS
- 8-10 years of progressive experience managing risk adjustment programs, with demonstrated success across prospective, retrospective, and concurrent models.
- Proven experience in a physician engagement model that involves working directly with physicians and primary care practices on documentation practices, pre-visit planning, and clinician behavior change.
- Deep familiarity with Medicare Advantage, ACO, and other value-based care models.
- Expertise with risk adjustment coding (HCC), documentation practices, RAF score drivers, and CMS submission requirements, compliance, and timelines.
- Expert knowledge of CPT2 and quality coding
- Strong command of risk adjustment tools, platforms, and vendors.
- Experience managing coding teams or vendors (clinical and non-clinical), and driving performance improvement.
- Skilled in using data and analytics to measure and optimize program performance.
- Excellent project management and communication skills, with the ability to lead cross-functional initiatives.
EDUCATION AND TRAINING
- Bachelor's degree required; advanced degree (MPH, MBA, MSN) or coding certification (CRC, CPC, etc.)
SALARY RANGE
- $140,000 – 160,000
Belong Health is an equal opportunity employer and encourages all applicants from every background and life experience to apply.
Our organization participates in E-Verify to confirm the eligibility of employees to work in the United States. (Nuestra organización participa en E-Verify para confirmar la elegibilidad de los empleados para trabajar en los Estados Unidos.)
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