Job Description

Your Role

The Risk Adjustment Provider Relations team provides essential support to all functions within the risk adjustment program, which includes interaction with various cross-functional teams within Blue Shield and Provider Groups. The Risk Adjustment Provider Partnership Manager will report to the Director, Risk Adjustment Provider Partnership. In this role you will be responsible for providing expertise in the area of risk adjustment for the Blue Shield providers. The Risk Adjustment Provider Partnership Manager will interface with provider group operational and clinical leadership to assist in identification of operational and clinical practices in maximizing recapture rates, understanding clinical suspects and monitoring of appropriate clinical documentation and accurate coding. The Risk Adjustment Provider Partnership Manager will also coordinate implementation of Blue Shield Programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow \xe2\x80\x93 personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Have overall responsibility and accountability for reviewing staff work product related to reserving, CMS/ACA related risk adjustment processes, pricing, forecasting, trend setting, and/or network development and alternative provider payment models
• Be responsible for developing and managing experience tracking reports, comparisons to plan, tracking and quantifying variances and shares insights with the business unit and management
• Ensure team follows existing work flow procedures or policies and/or validate or develop new procedures and policies
• Be responsible for understanding current and emerging regulatory and competitive developments, facilitating communication of these developments, and ensuring processes and procedures are consistent with changing regulations
• Lead special projects/ committees/task forces
• Strategically lead in a manner that ensures the Team works with Provider Groups to ensure accurate diagnostic coding and improvement of risk adjustment scores (RAF)
• Provides direction to Team to drive improvements in support of Provider Groups risk adjustment processes through developing comprehensive, provider specific plans to increase their RAF performance, improved their coding specificity with Provider Group consultation
• Utilize analytics and identifies targeted providers for Risk Adjustment training and programs through routinely consulting with Providers to clarify missing or inadequate information to determine appropriate diagnostic and procedure codes
• Reviews analysis to forecast and evaluate the performance of the Blue Shield Risk Adjustment Programs and refine annul risk adjustment strategies to achieve optimal performance
• Collaborates with providers, coders, facility staff and a variety of internal and external personnel on wide scope of Risk Adjustment and Quality education efforts

At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We\'re excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area\'s top companies in volunteering & giving, and one of the world\'s most ethical companies. Here at Blue Shield of California, we\'re striving to make a positive change across our industry and the communities we live in , Join us!

Blue Shield of California