Risk Adjustment Manager

It’s an exciting time to join the Well Sense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Manage and monitor day to day operational activities and various programs within risk adjustment department. Establish and track project KPIs, coordinate and support vendors in project execution, and work with both internal & external stakeholders to foster successful outcomes. Success will require a high degree of Risk Adjustment exposure, the ability to translate data into action, & a collaborative approach to solve complex situations with internal & external (providers) stakeholders.

The Manager will oversee all provider engagement and reporting activities for risk adjustment programs and initiatives that impact Medicare, Medicaid, and Commercial products. This individual will build relationships with internal provider relations teams and representatives at contracted provider organizations and leverage these relationships to assist in the retrieval of medical records, program engagement, and operational success in both prospective and retrospective risk initiatives.

• Full‑time remote work
• Competitive salaries
• Excellent benefits

• Coordinate risk adjustment program projects including developing project plans, workflows and timelines
• Track and communicate project status, time frames, deliverables, and KPIs to multiple stakeholders and department leadership
• Perform ongoing evaluations of provider‑facing programs, processes, infrastructure, and reporting to pinpoint areas for improvement and drive changes that maximize program performance and impact
• Build relationships with provider relations teams and provider offices
• Support retrieval of medical records for risk activities by leveraging relationships with providers and provider relations teams
• Manage day to day operations of vendors associated with risk adjustment department projects
• Partner with Risk Adjustment Leadership, Clinical, and Financial Analytics teams to define opportunities and areas of focus to optimize risk adjustment performance across all products and drive solutions.
• Partner with analytics staff to identify reporting opportunities that will assist in KPI tracking and streamlined workflows
• Lead current‑state assessments of provider organizations’ risk adjustment capabilities to evaluate performance and identify improvement opportunities.
• Other duties as assigned

None

General direction and guidance provided weekly or as needed.

• Bachelor’s Degree

• Masters Degree – Healthcare administration or related field

• Minimum of 5‑7 years’ experience in health care project management and program implementation or equivalent education
• Experience in a highly regulated setting with a focus on compliance & quality outcomes
• Experience having deadline driven work & meeting those deadlines

• Familiarity with risk adjustment or related healthcare payer programs preferred
• Understanding of value based payment structures across various products (Medicare, Medicaid, Commercial)
• Health Plan experience or experience managing programs within a provider’s office
• Experience implementing and operationalizing new programs

• Successful completion of pre‑employment background check

• Ability to think strategically and understand how program decisions impact overall business goals
• Ability to coordinate cross functional teams to execute complicated workflows and tasks
• Effective collaborative and proven process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• Demonstrated ability to successfully plan, organize and manage projects
• Act like an owner, be self‑driven and own the results
• Ability to run meetings independently as needed and create agendas that tie back to results
• Strong analytical and problem solving skills
  
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