AVP Stars and Risk Adjustment National Medical Director
Location: Bethesda, MD, United States
Employment Type: Full-Time
Posted on: Apr 28, 2023
Profile:
The Healthcare Quality Reporting & Improvement (HQRI) organization is seeking a talented Physician executive that can contribute to Humana's national planning and operations for Risk Adjustment, Stars, and Interoperability. This role will carry a set of individual contributor and leadership responsibilities.
Responsibilities:
- Inform and support HQRI's provider strategy across Stars, Risk Adjustment, and Interoperability.
- Serve as a coding expert to manage escalations or establish compliant policies.
- Contribute as a clinical industry representative.
- Lead HQRI's Provider Support team (PST) that drives national provider education strategy and operations along with provider communication operations.
This role relies on medical background, business acumen, and industry-standard clinical/coding guidance to ensure physician and healthcare provider plans, education, reporting, and materials are accurate and consistent across the enterprise to support regional and corporate strategic initiatives.
Major Responsibilities Include:
- Inform HQRI's provider strategy and increase adoption of Humana's Stars, MRA, and interoperability strategy and programs.
- Lead a team of 10 associates across three functions: education of Humana's market-based associates on accurate reporting; provider communications; policies and procedures aligned to those functions.
- Serve as HQRI's clinical industry representative (e.g., conferences; national vendor or provider partners).
- Serve as a coding expert, including working through escalations on coding disputes, policy development or refinement, and coordination and education with providers or Humana associates.
Required Qualifications:
- MD or DO degree.
- A current and unrestricted license in at least one jurisdiction.
- Board Certified in an approved ABMS Medical Specialty.
- Excellent communication skills, both written and verbal.
- 5 years of established clinical experience.
- Knowledge of the managed care industry including Medicare, Medicaid, and/or Commercial products.
- Passionate about healthcare quality and maintaining accuracy of coding and documentation to capture the true health status of members through risk adjustment initiatives.
- Experience with quality assurance and/or regulatory compliance.
- Travel up to 25%.
Preferred Qualifications:
- Certification in diagnosis coding (must receive AAPC certification within one year of hire).
- Ability to develop and use data and analytics to drive sustainable results.
- External communications for physicians and healthcare providers.
- Prior experience leading teams focusing on the accuracy of medical record documentation and diagnosis coding.
- Medical management experience, working with health insurance organizations, hospitals, and other healthcare providers.
- Working knowledge of risk adjustment concepts.
- Detail-oriented and effective listener.
- Experience with Stars, including HEDIS, CAHPS, and HOS.
- Prior experience in a business function or business consulting role.
Additional Information:
Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Scheduled Weekly Hours: 40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion.
Humana Inc.
Website: http://www.humana.com
#J-18808-Ljbffr
