Risk Adjustment Consultant at Tufts Health Plan in Watertown, Massachusetts

Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

Under the supervision of the Senior Manager of Risk Adjustment Strategy and Operations, this individual will support the operations and analysis of all risk adjustment programs and serve as the primary point of contact to a select portion of our provider network. This includes strategically important business partners, such as integrated delivery networks, large facilities and/or physician organizations. This individual will also work closely with internal departments and external vendors to ensure that risk adjustment programs are implemented and operated at the highest levels of performance. The S&O Consultant will also work closely with our Network Contracting, Clinical and Care Management departments to deliver timely reporting and performance management advisory services to our provider network. This individual regularly demonstrates self-direction and motivation toward completion of on-going department initiatives.

Job Description

Provider Engagement, Data Analysis and Risk Score Reporting
- Develop and maintain strong and effective working relationships with key business and medical leaders at provider organizations within our network
- Manage provider outreach and ongoing communications/reporting for all risk adjustment programs and initiatives. Serve as the risk adjustment subject matter expert to address provider concerns and assist them in understanding the complexities of risk adjustment programs and the resulting data
- Coordinate and facilitate regularly scheduled and ad hoc provider meetings to provide operational updates, discuss strategic initiatives and improvement opportunities
- Build and refine medical group-specific profiles including but not limited to governance, financials, risk scores, culture and technology
- Support the evaluation of medical group opportunities and challenges specific to risk adjustment performance, identify and/or modify training needs and/or programmatic interventions to improve performance and refine the engagement plans.
- Analyze, interpret and synthesize medical group specific results and risk score trend information; deliver the results of standard (and ad hoc) analyses to improve awareness and understanding of risk score results and the quality, accuracy and identification of member health conditions
- Work collaboratively with risk adjustment provider educator and the quality assurance team to focus the provider training and education specifically related to coding accuracy, documentation and risk adjustment to high impact providers
- Perform high level financial analysis on risk adjustment programs to evaluate and report financial impact to provider organizations
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Collaboration with Internal Stakeholders and External Vendors
- Develop effective and positive working relationships with internal partners (Network Contracting, Clinical Services, Sales and Marketing, Actuarial, etc.) to collaborate on provider engagement and performance improvement initiatives
- Collaborate and coordinate with internal partners in order to conduct comprehensive analysis and deliver professional presentations to our provider network at shared meetings
- Manage multi-faceted vendor initiatives to ensure smooth implementation and operations
- Support the Risk Adjustment department in efforts to assess additional diagnosis program opportunities that can be procured or potentially developed internally
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Administration
- Attend provider engagement meetings, document provider concerns and key decisions, manage follow up actions as necessary
- Stay informed about CMS and industry trends and best practices; utilize this knowledge to recommend modifications to THP's risk adjustment programs and provider engagement practices
- Support the development and refinement of key deliverables to our provider community, including presentations, reference material and communications

Requirements

EDUCATION: (Minimum education & certifications required)
Bachelor's degree required, preferably in related field. Graduate degree preferred.

EXPERIENCE: (Years of experience)
Three to five years of experience in a progressively responsible role with leadership experience in a complex operational setting or consulting role. Previous experience working in strategy implementation, analytical and process improvement in the health care / health insurance sector either for a health plan, provider group or management consultancy is a plus. Understanding of US Health Policy and experience working with CMS, health insurers and medical providers highly desired.

SKILL REQUIREMENTS: (Include interpersonal skills)
- Highly energetic, organized, detail-oriented, resourceful and self-motivated
- Highly proficient in Microsoft Excel, PowerPoint and Word; additional database systems a plus
- Excellent interpersonal and communication skills
- Ability to work collaboratively with both internal and external resources
- Ability to develop professional and effective relationships as a strategic advisor to our provider network
- Ability to take responsibility, prioritize tasks and follow through to completion
- Ability to organize, manage, and analyze large sets of data

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
- Must be able to excel in a fast paced business environment and handle multiple priorities. Must be highly effective in both written and oral communication
- Must be able to exercise appropriate judgment when making decisions
- Must be able to work in excess of 40 hours per work as the job may require, including evenings and weekends

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!.

Tufts Health Plan is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here. If you d like more information on your EEO rights under the law, please click here.