Risk Adjustment Manager at Horizon Blue Cross Blue Shield of New Jersey in Newark, New Jersey

Job Description:

Job Summary:

This position is responsible for managing, facilitating and managing cross-functional projects, programs and processes to deliver defined outcomes, on time, in support of risk adjustment process and operations. The manager will plan, organize, execute, monitor, and oversee multiple projects/processes to meet risk adjustment department needs. They will work closely with other risk adjustment leaders, teams and additional internal and external stakeholders contributing to the success of enterprise risk adjustment.

• Lead projects to define, create, and implement best in class risk adjustment processes, including the facilitation and creation of relevant standard operation procedures (SOPs)


• Assist with the development and execution of risk adjustment compliance program to ensure initiatives and processes reflect appropriate balance between risk mitigation and full burden of illness accuracy and completeness


• Facilitate, track and monitor internal and external risk adjustment coding audit processes including National RADV, Vendor Q&A Audits, documentation and process management etc.


• Manage and communicate a clear vision of the project/programs/processes and motivate the supporting teams to achieve objectives; create an environment that enables peak performance by team members.


• Provider regular reporting on the status of process & operations, with actionable insights to department and enterprise leadership.


• Author presentation materials including research, best practices, and initiative results for internal & external leadership audiences.


• Manage relationships with project/process stakeholders, including internal divisions, departments, teams and external clients & vendors, keeping them informed of progress and issues in order to manage expectations on all requirements and deliverables.


• Establish and communicate clear priorities among project/program activities; manage and resolve issues and risks, escalating as appropriate and track to resolution.


• Ensure projects, programs, processes deliverables and outcomes meet federal (CMS/HHS) and State regulations and guidelines


• Assist with vendor onboarding by defining the work/process flows that vendors are completing.


• Determine best practices and efficiencies on vendor related tasks such as date exchange, reporting, member and provider outreach etc.

Education/Experience

• Requires Bachelor's degree from an accredited college or university.


• Requires a minimum of 5 year of experience preferably in the health insurance industry with a least 3 years of project, program management support


• Requires 2+ years of Risk Adjustment experience


• PMP, Agile certified practitioner, certified scrum master preferred

Knowledge

• Detailed knowledge of risk adjustment, health plan operations and project management methodologies.


• Background sufficient to understand the technologies, processes, and interactions issues within the industry, anticipate and identify obstacles, and make appropriate decisions.


• Clear vision of what determines a successful project/program,

Skills and Abilities

• Excellent documentation skills


• Good oral skills


• Process improvement mindset


• Personal integrity and to escalate issues about projects, programs and processes to leadership when necessary,


• Ability to work well with people from many different disciplines with varying degrees of both technical, operations experience


• Competence in clear, concise and tactful communication with senior leadership, peers, staff, and stakeholders.


• Strong PC skills and expertise in MS-office suite (including MS-Project and Visio).

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status or status as an individual with a disability.

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