Vice President, Risk Adjustment Strategy
At UpStream, we are dedicated to promoting good health and empowering individuals to lead independent lives. As a trusted partner to primary care physicians, we offer effective and sustainable care options, focusing on seniors and those with chronic conditions. Our comprehensive solution allows physicians to prioritize patient care while our value-based care model ensures effective condition management.
We prioritize affordability and accessibility, collaborating with healthcare practices and clinics to reduce costs and enhance system efficiency. Through personalized care plans and innovative solutions, we strive to improve health outcomes and enable patients to live fulfilling, independent lives.
How you’ll help
The Vice President, Risk Adjustment Strategy is responsible for refining, coordinating, communicating and managing a strategic Medicare Risk Adjustment program, including HCC/diagnosis code accuracy, diagnosis code submission and auditing. In this role, you will directly lead the Medicare Risk Adjustment team and is responsible for establishing, monitoring and achieving recapture rates, engagement and education initiative metrics while ensuring all processes are compliant. This role will closely integrate with UpStream’s Finance team to analyze coding accuracy and submission, as well as partner closely with our Legal and Compliance teams.
This role is responsible for managing the UpStream Clinical Documentation Managers in the market. Additionally, this role will assist in the talent selection and hiring process of clinical documentation managers, including training and onboarding, and will oversee the Clinical Documentation Team. This role will monitor performance and coaching as needed, and continually identify opportunities for process improvement while ensuring teams are using standardized processes. Additionally, this role assist with training internal UpStream employees on RAF concepts and will act as a SME to the RAF team and UpStream leadership team.
The Vice President, Risk Adjustment Strategy will coordinate with other market and UpStream resources to disseminate education to the providers in the market through a variety of methods, while tracking provider engagement rates and collaborate to improve engagement rates as needed. This role will help determine and prepare the RAF resources needed for use throughout the markets.
This position reports to the Vice President, Value-Based Performance.
What you’ll do
- Play a critical role in the development and implementation of strategies to improve RAF accuracy and completeness, while making necessary adjustments as needed
- Partner with UpStream’s Finance team to develop and monitor reports for CMS financials, cost analysis and return on investment while maintaining high quality of clinical care
- Create, monitor and report on KPIs for the risk adjustment team, including but not limited to recapture rate, engagement and other process measures
- Collaborate with vendors and analytics team to ensure data integrity
- Evaluate current action plans created by RAF managers and develop best practice processes to achieve efficiency and accuracy
- Support the market and internal UpStream teams by implementing best practices for quality care measures to ensure highest level of performance
- Partner with UpStream Legal and Compliance teams to regulate, monitor and ensure compliance with regulatory and accrediting bodies, including Centers for Medicare, Medicare Advantage, etc.
Experience and skills you’ll need
- Bachelor’s degree required; master’s degree in Finance, Business Administration or Health Administration strongly preferred
- 7+ years Risk Adjustment program experience required
- Previous leadership experience required, with the ability to work with a diverse group of individuals throughout the organization
- Extensive knowledge of value-based care and quality metrics, such as HEDIS, STARS, etc.
- Ability to distill complex RAF-related information and topics and tailor communications appropriately for the audience
- Strong knowledge of risk adjustment financial concepts and reporting
- Extensive knowledge of Risk Adjustment and Hierarchical Condition Category (HCC) coding payment models required
- Demonstrated experience with claims, encounters, and CMS submission processes related to risk adjustment
- Desire to be a hands-on leader with a track record of “rolling up your sleeves” to drive desired outcomes
- Proven experience operating successfully within ambiguity; a results-oriented professional who can make sense of chaos to continually deliver desired results
- Demonstrated organizational skill and the ability to effectively manage competing priorities
- Excellent interpersonal communication and critical problem-solving skills; willingness to challenge yourself and others and take calculated risks to grow the business
- A passion for healthcare and desire to be part of a fun, growing team
- Demonstrated humility with visionary leadership and a dedication to service
- Remote from Eastern or Central Time Zone
- Occasional travel required
At UpStream we offer a range of benefits to ensure our employees are taken care of. Our health insurance plans through United Health Care include FSA and HSA options, and we also offer dental, vision, life, and accident coverage through Guardian. We immediately match contributions to our 401k plan, which includes both Roth and Traditional options. In addition, we provide financial perks and rewards through BenefitHub, and free access to EAP services through WorkLifeMatters. Our employees also enjoy generous PTO and paid holidays.
We value diversity and promote equal opportunities for all. As an equal opportunity employer, we do not discriminate against applicants based on their race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. All qualified candidates are encouraged to apply.