Remote Risk Adjustment Auditor Jobs in Margate, FL

JOB DESCRIPTION Job Summary

Ideal Candidate will have: Direct experience designing and implementing Value-Based Contracts, including shared savings, shared risk, capitation, and other CMS-aligned Alternative Payment Models (LAN Categories 2-4) for Medicare and/or Medicaid populations.

Leads and directs team responsible for value-based programs (VBP) activities. Responsible for developing and implementing value-based strategies for lines of business impacted by the regulatory risk adjustment payment model. Supports achievement of financial and business objectives through value-based reimbursement.

Essential Job Duties

• Accountable for designing and implementing strategies to continuously improve results of existing value-based initiatives while also leading a continuous process of innovation to identify new initiatives which lead to the overall achievement of improved accuracy, compliancy and completeness in risk adjustment revenue for all government lines of business (LOB). 
• Supports the strategic direction and organization of corporate initiatives to facilitate achievement of value-based financial strategy and business objectives.
• Serves as primary owner of value-based programs (VBP) and contracts annual plan by state by line of business (LOB) development and execution. 
• In conjunction with health plan and quality and risk adjustment leadership, identifies providers for potential value-based care contracts, assists local network and corporate network teams in reaching out to targeted providers, develops suggested contract terms (financial and quality metrics and benchmarks, assignment of reporting responsibilities and functions within contract language etc.), sets annual targets for each value-based program (VBP)/value-based contract (VBC), and develops reports for local health plan resources to share on a regular cadence with providers to achieve goals. 
• Collaborates with risk adjustment to leverage the needs assessment for specific area to guide the contracting and program strategy to achieve desired VBC/VBP goals. 
• Designs and maintains an internal dashboard of value-based programs and contracts by state by LOB for internal monitoring and senior leadership ensures consistent measurement of all metrics to enable accurate comparisons and measurement of progress toward annual goals supporting financial forecasts.
• Supports launching of value-based programs in new markets/expansion of existing markets to achieve goals in requests for proposals (RFPs) and financial forecasts.
• Presents VBC/VBP/reimbursement performance to senior leadership in monthly/quarterly leadership meetings designs an oversight process for internal monitoring of existing contracts within the Molina leadership team.
• Ensures value-based contracting/reporting data and reporting internally and externally are accurate.
• Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration.
• Develops and sustains a high-performance team, dedicated to best-in-class solutions responsible for attracting, developing and retaining top-tier talent to support strategy and long-term business objectives.
 

Required Qualifications

• At least 8 years of managed care experience, including value-based programs (VBP) experience, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Experience leading value-based program and contract design, and implementation for Medicaid, Medicare, and/or Marketplace programs. 
• Experience in a complex health care delivery environment, specifically with government sponsored programs, including risk revenue management, strategy and compliance.
• Knowledge of value- based programs (VBP), risk adjustment models, quality metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare STARS, and coding.
• Knowledge of medical economics and financial reporting, and ability to walk stakeholders through complex financial reconciliations.
• Leadership skills, including ability to influence others who are not in a direct reporting line including ability to think strategically, develop vision, and execute effectively and efficiently for both near-term and long-term results.
• Proven ability to innovate and manage complex processes across multiple functional areas.
• Experience working in a highly matrixed organization, and proven ability to develop internal enterprise relations, and external strategic relationships.
• Excellent verbal and written communication skills, including ability to present at an executive level to internal/external stakeholders.
• Microsoft Office suite and applicable software program(s) proficiency.
 

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

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Pay Range: $97,299 - $189,732.18 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.