Director, Risk Adjustment Operations
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Job Description
Director of Risk Adjustment Operations at Devoted overseeing data submissions and chart reviews. Leading operational success with metric-driven strategies and AI tool integration.
Responsibilities:
- This role owns the end-to-end operational success of two core pillars within Devoted’s Risk Adjustment Department: Data Submissions and the Retrospective Chart Review Program.
- Lead the teams responsible for the successful submission of Devoted’s disease burden reporting by optimizing our internally developed Centers for Medicare & Medicaid Services (CMS) data submission engine.
- Manage a high volume, multi-vendor retrospective medical document review operation.
- Develop, implement, and achieve KPIs that measure and monitor the successful submission of our risk adjustment data.
- Manage relationship with Devoted’s data submission pass-through vendor, and CSCC Operations, CMS’ data submission team.
- Read and make determinations on how new and emerging CMS technical guidance impacts our data submission operations.
- Maintain our data submission policies, including our policy on how we internally validate, clean, and apply inclusion and exclusion criteria to the data we submit to CMS.
- Support other areas of the Risk Adjustment department to ensure end-to-end perspectives are considered for all policy and procedure decisions.
- Lead the strategic execution of the multi-channel Retrospective Chart Review Program, including defining, monitoring, and enforcing rigorous Service Level Agreements (SLAs) and Key Performance Indicators (KPIs) for internal teams, offshore partners, and external vendors.
- Oversee medical record retrieval in partnership with the Clinical Data Acquisition team.
- Own and improve program forecasts and capacity modeling.
- Evaluate and integrate AI technologies to optimize the end-to-end chart review workflow, from medical record retrieval through evaluation.
- Support QA and audit processes to achieve or exceed 95% coding accuracy.
- Support other areas of the Risk Adjustment department to ensure end-to-end perspectives are considered for all policy and procedure decisions.
Requirements:
- Proven operator with a track record of transforming complex operational challenges into scalable, practical, and elegant business processes
- Systematic and detail-oriented approach to leadership, with a fierce commitment to quality, accuracy, and operational excellence
- Deeply analytical and research-oriented, with the ability to digest intricate regulatory or technical guidance and seamlessly incorporate it into daily operations
- Ability to manage and lead through ambiguity
- Can-do attitude and stamina for tackling hard problems
- High level of self-motivation and an ability to balance multiple priorities across initiatives
- Results-oriented: you are energized by having an ambitious goal and the latitude to execute against it
- Natural relationship builder and able to work well in a cross functional team environment
- Experience managing multiple teams and vendors
- Fast learner, can pick up new content/industries quickly in an extremely fast-paced tech environment
- Proven organizational, communication, and leadership skills
- Prior experience in Medicare Advantage risk adjustment, in particular RAPS and EDPS data submission and retrospective chart reviews preferred but not required.
Benefits:
- Employer sponsored health, dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
- Parental leave program
- 401K program
- And more....
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