Risk Adjustment – Risk Management Lead

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The Risk Management Lead acts as a consultant to the Risk Adjustment team leaders, as programs and initiatives are executed upon. Leveraging risk management and compliance frameworks, they will identify and analyze potential risks and sources of loss to evaluate business processes and drive improvements aimed at minimizing risk. The Lead will focus on Project Management and is responsible for oversight of the Risk Adjustment Operations processes.

The Risk Management Lead works on problems of diverse scope and complexity ranging from moderate to substantial.

The Risk Management Lead estimates the potential financial consequences of an occurring loss. Develops and implements controls and cost‑effective approaches to minimize the organization's risks. Assesses and communicates information regarding business risks with functions across the organization. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision.

Uses independent judgment requiring analysis of variable factors and determining the best course of action. In addition, this role provides consultative services to drive efficient, effective, and compliant risk adjustment processes.

This Risk Adjustment Risk Management lead position will be responsible for providing risk management and compliance oversight of Risk Adjustment Operations, including the areas of Provider Data Validation, Provider Support, Provider Reporting, Quality Audit, and risk adjustment operations related to Provider Reconciliation and alternative encounter submission methods. Responsibilities of the role will include the following:

• Evaluating processes and procedures to ensure adequate controls are included
• Monitor compliance requirements specific to risk adjustment operations
• Conduct audits to ensure controls and processes are being executed with minimal risk
• Conduct risk assessments, as necessary, to identify current gaps in processes
• Collaborate with business area associates to develop remediation plans to close gaps
• Collaborate with business area teams and compliance partners to consult on initiatives and drive process excellence
• Develop annual work plan for responsible areas
• Understand and assist in financial control assessment and work collaboratively with internal and external auditors
• Evaluate Provider Data Validation, Provider Reporting, Quality Audit, and core risk adjustment operational business areas monthly progress against goals
• Track and report on project status

• 3 or more years of project leadership experience
• 2+ year of audit, compliance, and/or risk experience
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Strong relationship building skills
• Ability to take the initiative
• Ability to manage multiple initiatives at a time and ensure progress is moving forward

• Applicable Bachelor's degree - Accounting, Finance, Business, Auditing, Actuarial
• Certified Internal Auditor, CPA or CPC strongly preferred
• Risk Adjustment knowledge
• Experience with risk adjustment provider data and reporting
• Auditing experience
• Familiarity with CMS Reimbursement models and claims/encounter submission processes
• Data analysis and dashboarding experience
• People leadership experience

Location:

Nationwide (U.S.); however, candidates located in the Eastern Standard Time (EST) Zone are strongly preferred to support alignment with team schedules and collaboration.

• WAH requirements:
  Must have the ability to provide a high‑speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
• Satellite and Wireless Internet service is NOT allowed for this role.
• A…