Job Summary:
The primary purpose the Senior Director, Compliance, Risk Adjustment is to provide oversight and maintenance of a high-quality, effective, best practices risk adjustment compliance program to prevent and detect violations of law and other misconduct and to promote ethical practices and a commitment to compliance with applicable federal, state, and local laws, rules, regulations, and internal policies and procedures. This position plays a key role in providing direction for the risk adjustment compliance function as well as maintaining enterprise-wide view of risk adjustment compliance activities. Risk Adjustment includes the following lines of business: Medicare Advantage, Affordable Care Act (ACA) and Medicaid.
Core Responsibilities:
In addition to the key responsibilities listed below, the position serves as a compliance subject matter expert related to risk adjustment rules, regulations, and policies by line of business, including risk adjustment coding, oversees internal and external audit (RADV) activities related to risk adjustment, monitors compliance with enterprise-wide risk adjustment policies and procedures, provides support for teams to stay abreast of the latest rules, regulations, and policies by line of business and coding/billing developments impacting risk adjustment, and monitors the accuracy and quality of coding/billing assignments impacting risk adjustment. Additionally, this position is responsible for developing the annual risk adjustment compliance work plan in alignment with business objectives, reviews audit results, sets the direction for risk adjustment compliance reviews and focused projects related to audit outcomes, and enforces compliance and the Code of Ethical Conduct: Kaiser Permanente's Principles of Responsibility.
The Senior Director, Compliance, Risk Adjustment demonstrates continuous learning and maintains a highly skilled and engaged workforce by aligning resource plans with business objectives; oversees the recruitment, selection, and development of talent; motivates teams; prepares individuals for growth opportunities and advancement; stays current with industry trends, benchmarks, and best practices; provides guidance when difficult decisions need to be made; and adheres to performance management guidelines and expectations drive business needs.
Essential Responsibilities:
- Demonstrates continuous learning and maintains a highly skilled and engaged workforce by aligning resource plans with business objectives; overseeing the recruitment, selection, and development of talent; motivating teams; preparing individuals for growth opportunities and advancement; staying current with industry trends, benchmarks, and best practices; providing guidance when difficult decisions need to be made; and ensuring performance management guidelines and expectations drive business needs.
- Oversees the operation of multiple units and/or departments by identifying customer and operational needs; analyzing resources, costs, and forecasts and incorporating them into business plans; gaining cross-functional support for business plans and priorities; translating business strategy into actionable business requirements; obtaining and distributing resources; setting standards and measuring progress; removing obstacles that impact performance; guiding performance and developing contingency plans accordingly; and ensuring products and/or services meet customer requirements and expectations while aligning with organizational strategies.
- Oversees company compliance activities by ensuring team members, including external business partners, provide support to internal and external stakeholders; reviewing and approving compliance activities; designing strategies for the implementation of regulations and regulatory changes; ensuring compliance activities are fully documented; and overseeing the resolution of compliance issues.
- Directs compliance reporting efforts across multiple business functions by overseeing the evaluation and summary of compliance data, audit information, and potential risks and remedies; identifying and reporting key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations) to senior management; and developing complex presentations to convey key findings to executive leadership and external business stakeholders.
- Directs compliance investigations across multiple business functions by overseeing the collection and analysis of quantitative and qualitative data; conducting interviews on escalated issues as appropriate; reviewing and evaluating research on key business issues; and evaluating and recommending corrective action plans for substantiated allegations.
- Directs programs or compliance components of larger cross-functional programs by identifying and managing stakeholder contacts; assembling teams based on program needs and team member strengths; developing, analyzing, and managing program plans; negotiating and managing program schedules and resource forecasts; and managing program financials and deliverables.
- Directs activities associated with continued regulatory compliance for multiple business functions by monitoring, interpreting, and designing strategy around regulatory changes; determining the impact of changes to the business; providing direction on implementation of changes throughout the business; and providing regulatory input before and during inspections to minimize the risks of future non-compliance.
- Directs and oversees the implementation of compliance efforts by approving compliance requirements; ensuring the assessment of current state compliance to identify gaps and corrective actions; overseeing the analysis and development of complex compliance standards, policies and procedures, and training; and ensuring the monitoring of ongoing compliance adherence.
- Responsible for overseeing risk adjustment compliance activities for Medicare Advantage, Affordable Care Act (ACA) and Medicaid.
- Provide leadership and direction to ensure alignment between the business functions and Risk Adjustment Compliance.
- Develop, implement, and manage programs related to risk adjustment including, but not limited to, HCC/diagnosis code accuracy, diagnosis code submission,and Risk Adjustment Data Validation (RADV) Audit.
- Monitor and refine existing risk adjustment programs.
- Minimize risks by staying current on regulations, assess and analyze their significance and impact, and recommend policies to ensure compliance.
- Stay abreast of industry changes and/or trends including, but not limited to, federal Risk Adjustment cases, and provide awareness to compliance, legal, and business owners on potential risks, issues, and policy enhancements.
- Develop and direct internal risk adjustment compliance initiatives, audit and monitoring activities (e.g., risk assessment, audit work plan development and execution,audit readiness activities, etc.)
- Collaborate with all areas of ethics & compliance, the special investigations unit, Legal, and business owners to identify potential risks and to drive process improvements.
- Collaborate with business owners to ensure alignment between Revenue Management Compliance and the business.
- Develop and communicate/present compliance reports to leadership, business owners and established committees.
- Responsible for reviewing policies and procedures for designated business areas to ensure regulatory and risk adjustment compliance.
Minimum Qualifications:
- Minimum six (6) years experience in a leadership role with or without direct reports.
- Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum twelve (12) years experience in compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field. Additional equivalent work experience in a directly related field may be substituted for the degree requirement.
Additional Requirements:
Preferred Qualifications:
- Master’s degree or equivalent.
- 10+ years of experience with Medicare Advantage, Affordable Care Act (ACA) and/or Medicaid Risk Adjustment is highly preferred.
- Experience leading a team of professionals is highly preferred.
- Expert knowledge of Medicare Advantage, Affordable Care Act (ACA) and/or Medicaid Risk Adjustment, compliance and regulations is highly preferred.
- Strong knowledge of Risk Adjustment and the current Hierarchical Condition Category (HCC) coding payment model (e.g., v24 and v28 ) is highly preferred.
- 10+ years management/leadership experience.
- 5+ years of experience with auditing.
- Coding certification preferred but not required.
- Strong knowledge of claims, encounters, risk adjustment and CMS submission process is highly preferred.
- Experience with Risk Adjustment Data Validation Audits preferred but not required.
- Strong leadership and interpersonal skills with the ability to work with a diverse group of people across the organization and externally.
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