Job Description

Job Summary

The AVP, Risk Adjustment Encounters is responsible for establishing enterprise-wide strategy, governance, and oversight of processes that track, evaluate, and submit encounter deletions for Medicare Advantage, ACA, and Medicaid lines of business. This role has decision-making accountability for ensuring compliance with complex regulatory requirements, protecting the integrity of enterprise revenue, and enabling the organization’s overall risk adjustment strategy.  

 Knowledge/Skills/Abilities

Responsible for encounters accuracy & completeness (i.e., Encounter Production, Audit, Production Vendor Oversight) for assigned lines of business. Responsible for increasing volume of encounters received from providers, improve completeness of encounter data with states, CMS, HHS to reconcile data. Responsible for encounter submissions, rejection management & resolution for all lines of business including internal strategic partnerships supporting the production of encounters as well as provides leadership support at managing overall healthcare costs. Ability to influence across multiple organizational functions — Payment Integrity, Claims, Encounters, Finance, and Actuarial  Proven experience in managing complex projects, including the ability to design and implement efficient enterprise-wide processes and governance structures that span claims, encounters, clinical, finance and actuarial functions.

  Identifies, develops and trains appropriate staff and implements processes to standardize the overall ends-to-end processing, management and accuracy of encounters, as well as working with partner departments to implement process improvements impacting quality and timeliness of encounters processing and accuracy. Ongoing monitoring and management resolution for any potential penalties related to accuracy and timeliness of encounters submissions. Manage projects/initiatives that reduce administrative costs for Molina and/or providers as well as identifies opportunities to ensure accurate encounters are occurring to assist in the management of the organizational health care costs for all lines of business and directly impacting Risk Revenue and Quality Compliance. Partner with VP Encounter to ensure alignment of business goals and objectives for cost saving. Convenes work groups, develops implementation plans with identified tasks, timelines and assigned parties. Executes and measures success. Partner with VP Encounter to participate in the Corporate Operational Leadership Team along with IT to analyze the root cause of information of variations to the encounters, to find/propose ways to improve upon performance results, to identify potential risks to the organization and to lead the needed changes within the encounters process to support the organizational needs in all lines of business. Collaborate with leadership, peers, and business partners to establish encounters improvement objectives and execute business priorities based on strategic goals in the operational plan. Manages direct Molina staff as well as oversees vendors to enable the organization to produce operational results at the lowest possible cost, the most consistent and compliant service levels, and the highest level of quality for all lines of business. Ensures all state, federal and Molina regulations, Policies/Procedures and SOPs are implemented and followed on a consistent basis to ensure the highest compliance possible within the Encounters Department. Assists VP Encounter with managing costs to meet/exceed annual budgets and finds ways to improve productivity and automation wherever possible to reduce unit costs and overall G&A for the organization. Identify and implement systematic approach to improve member and encounter first pass rate, increase operational efficiency, and effectiveness.

 

Knowledge/Skills/Abilities

8+ years Healthcare or Operational experience in related job. 2 years minimum in Director level role or above. Extensive understanding of Medicare Advantage, ACA and Medicaid risk adjustment processes, including encounter data submission and deletion requirements Accountability for multiple markets or product lines. Experience  with managing department budget within prescribed parameters. Experience with account management and vendor management. Excellent verbal and written communication skills. Ability to influence and drive change among peers and others within the Molina organization. Skill to envision, craft proposals, obtain consensus around approving and implementing future state processes and systems needed to support strategic direction set by organization.

 

Job Qualifications

REQUIRED EDUCATION:

Bachelor's Degree or equivalent experience

 

 

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.