Sr. Manager, Risk Adjustment & Quality
WHO WE ARE
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
Centrum Health’s Sr. Manager of Risk Adjustment and Quality will be responsible for managing a team of Risk Adjustment Coders, HEDIS specialists, Billers, and Auditors to maintain daily billing and coding operations for our wholly owned clinics and affiliated practices. In this role, the candidate must excel at cross-departmental collaboration with Physicians, Clinical Operations, Data/Technology, and Finance teams.
The individual must be a subject matter expert in ACA, Medicare Advantage, Medicaid risk adjustment, billing, and quality operations. The position delivers best-in-class results while operating under strict regulatory adherence and a strong compliance mindset.
This is an onsite position in Doral, FL.
ROLE RESPONSIBILITIES
• The core function of this role includes management of risk adjustment, medical records, coding, and billing operations.
• Lead a team to drive risk adjustment performance across Medicare Advantage, ACO, Medicaid, and ACA lines of business.
• Provide thought leadership in the continued development of the Risk Adjustment and Quality function, including collaboration with analytics and internal technology teams to develop a Risk Adjustment and Quality Suspecting Engine.
• Work closely with internal technical teams to develop in house tools to support Risk Adjustment operations.
• Provide leadership and overall program management for retrospective and prospective encounter facilitation, supplemental data submission, virtual visits, and in-office assessments.
• Collaborate with Actuarial and Analytics teams to design and implement suspecting and segmentation strategies for prospective and retrospective programs.
• Develop short-term, quick-win initiatives as well as long-term, analytics-driven gap-closure programs and tools.
• Communicate complex concepts to non-technical business stakeholders across the full business cycle—from question identification through results interpretation—including data integrity considerations.
• Ensure Centrum Health’s ability to meet federal and state regulatory compliance and reporting requirements, including RADV audits, on an annual basis.
• Perform other duties and responsibilities as assigned.
• This position will have direct and indirect supervisory responsibility for risk adjustment program execution and analytics functions.
• Occasional travel may be required.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree in a healthcare-related field or equivalent experience, required.
- Six (6) or more years of experience in healthcare Risk Adjustment required.
- Experience working with primary care providers and practices in value-based care.
- Three (3) or more years of leadership experience managing and mentoring teams.
- CPC, CRC, and CPMA certifications are highly preferred.
- Experience working with Medicare Advantage, ACA, and Medicaid health plans is preferred.
- Working knowledge of business intelligence tools and their application in driving business decisions.
- Experience with in-home and virtual engagement capabilities, preferred.
- Bilingual in Spanish and English required.
PROFESSIONAL COMPETENCIES
• Ability to lead and mentor a highly skilled team.
• Ability to frame and execute end-to-end analyses in collaboration with business and technical stakeholders.
• Expertise in advanced data analysis to identify opportunities and design programs to capture value.
• Experience managing third-party service providers, including TPAs and medical record/chart retrieval functions.
• Eager learner; collaborative partner; clear communicator; and detail-oriented analyst.
• Strong passion for empirical research and data-driven decision-making.
• Experience maintaining payer file integrations and developing performance dashboards using data from multiple reporting sources.
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