Manager, Medicaid Risk Adjustment

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Position Summary

We have an outstanding opportunity for an enthusiastic team player to lead a suite of market focused Risk Adjustment Programs for a portfolio of Aetna Better Health Medicaid Plans. Reporting to the Senior Manager of Medicaid Risk Adjustment, the Market Manager of Medicaid Risk Adjustment will work closely with cross-functional leadership across the Medicaid business to establish and champion a local market culture committed to revenue integrity excellence. This position is responsible for reviewing all activities (programs, analysis, encounter data submission and quality assurance) across revenue integrity processes related to risk adjustment (RA) focused on complete and accurate diagnosis capture and reporting. This position will drive RAF performance through the delivery of measurable programs with actionable solutions.

• Strong preference for this position to be hybrid, within a commutable distance to a CVS/Aetna Hub Office (i.e. Hartford, CT, Lansing, MI, Scottsdale, AZ, Miami, FL, Woonsocket, RI, Chicago, IL, Dallas, TX, Boston, MA, etc.)

Responsibilities

% Time

Strategy & Execution 40%

• Oversees a program or programs that is jointly accountable for risk adjustment strategy, performance, and results within a designated market(s).

• Responsible for identifying and recommending nuanced market risk adjustment strategies and collaboratively executing tactics to focus, maximize and achieve market success, including market referrals.

• Execute on local market strategies to drive correctness, completeness, accuracy, and timeliness of risk score performance.

• Jointly identify VBCs/non-VBCs to prioritize with risk score performance initiatives including developing strategy on members, VBC providers, and providers that get embedded coder training.

• Ensure SOPs and P&Ps are updated annually or developed for new projects.

Data Analysis & Reporting 20%

• Work closely with the Informatics team to review requirements, dashboards, reports including any enhancements.

• Utilize data analyses using national tools in conjunction with the corporate lead to identify areas of opportunity.

• Produce and present dashboards specific to Medicaid Revenue Integrity efforts at various governance, market, and executive leadership meetings.

3.Market Support & Performance Management 20%

• Act as a face of Revenue Integrity across internal market teams..

• Investigates operational issues that impact market performance - working with business partners to implement solutions.

• Assist with development of educational material as a result of claims data or provider requests.

• Support local market colleagues in ensuring strategic and optimal product and pricing discussions, including attending and hosting trainings.

• Manage and direct local vendors when appropriate.

• Engage with clinical team and specific clinics, medical groups, hospitals; attends JOC meetings; Supports engagement managers and RN program managers.

Leadership and Innovation 20%

• Recruit, develop and retain a high performing, high quality risk adjustment talent pool that is respected within Medicaid Operations.

• Develop the skills and abilities of all team members to optimize their performance and create sucession plans for future leaders that can take on roles with increasing responsibilities.

• Stay abreast of regulatory changes and leading risk adjustment practices and tools to maximize the effectiveness and efficiency of the team.

• Partner with segment product, sales, network, clinical teams to implement processes aimed at strengthening member and provider engagement of Revenue Integrity programs resulting in improved outcomes.

Required Qualifications

• 5+ years professional business experience, including

• 2+ years of demonstrated proficiency in delivering presentations to Senior Executives.

• Self-starter who demonstrates initiative and displays a high energy level

• Thinks and acts strategically

• Anticipates opportunities and challenges and drives long-term strategies while maintaining focus on shorter-term objectives.

• Highly developed relationship building and influencing skills to foster effective working relations across the teams, including functional and divisional leaders.

• Powerful communications skills and awareness of audience to properly convey information in a meaningful, yet concise manner.

• Intellectual curiosity and tenacity: strong ability to learn on the fly; to understand and solve complex problems.

• Analytical rigor: proven capability conducting and managing quantitative analysis with the highest level of attention to detail.

Preferred Qualifications

• 2+ years of experience in the health care industry, Medicaid operations, risk adjustment, or medical coding and documentation preferred

• Knowledge of insurance regulatory and contractual requirements.

• Master's degree or management development program preferred.

• Deep knowledge of local markets across Aetna Medicaid. Extensive data analytics experience RN, AAPC, or Certified Professional Coder (CPC)

Education

Bachelor's Degree required from an accredited four year college or university, or equivalent experience.

Pay Range

The typical pay range for this role is:

$63,300.00 - $139,200.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 05/10/2024