Director, Risk Adjustment
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
The Director of Risk Adjustment (RA) coordinates and oversees the analysis, monitoring, reporting, and forecasting of RA activities for the Government Programs lines of business, such as Medicare Advantage, Commercial Individual and Small Group and Medicaid member populations. This position keeps abreast of new RA legislation and regulations and is responsible for analyzing and communicating the potential impact to the rest of Community Health Choice. This position leads the alignment of all Risk Adjustment initiatives occurring within other functional teams such as Quality, Compliance, Operations, Legal, and Actuarial to improve the completeness and accuracy of RA data submitted to CMS and HHS. The Director identifies opportunities to improve all encounter data submitted to CMS, as submissions are leveraged to calculate risk scores, which directly impact revenue. The Director collaborates with the operations team responsible for managing encounter data submissions to CMS and the HHS EDGE server, leading studies, modeling risk scores and providing supporting analysis to improve RA performance. This role also serves as a liaison with vendors and is responsible for monitoring, executing, and enhancing the success of RA initiatives.
- Bachelor's degree (Business, Economics, Public Health, or another related field) required.
- Master's degree or extensive experience in healthcare industry preferred.
- Ten years in healthcare industry, specifically data management required.
- Seven years as an executive of healthcare data /analytics required.
- Ten years of progressive management / leadership in financial and performance management required.