The Sr Director, Risk Adjustment Strategy and Program Management is responsible for leading risk adjustment strategy and related revenue management for Florida Blue Medicare. This individual leads development and implementation of programs and initiatives to improve coding accuracy, including education; retrospective and prospective review processes; vendor reliance; accountability for preparation for and management of the Center for Medicare and Medicaid Services (CMS) auditing processes; management of encounter data processes; and management of applicable state and federal guidance. The Sr Director, Risk Adjustment Strategy and Program Management works collaboratively with Florida Blue Medicare, Florida Blue, and GuideWell executives and leadership to lead risk adjustment strategy and process.

Job duties include but are not limited to:
* Directs and oversees risk adjustment strategy, including prospective and retrospective chart review and procurement processes; internal and external audits preparation and risk mitigation; data analysis to support risk revenue accruals; CMS encounter data submissions for FBM's Medicare Advantage membership to ensure complete and accurate risk capture. This requires seamless integration with multiple service functions (e.g. actuary, performance management and audit, vendor management, project management, capability development, and provider education). Establishes goals and policies with the directors of operational and analytics teams, continually challenges leaders and their teams to evaluate processes and capabilities to further improve efficiencies and evaluate performance management of the team
* Provides strategic leadership to influence corporate strategy relative to FBM's risk adjustment strategies and continues to develop and evolve coding accuracy in concert with the Medicare Advantage industry and federal regulation. Collaborate with network leadership; and support vendor / provider partnerships - including data / information sharing, reporting, tools, and resources - to drive more accurate risk capture and revenue program management. Drives strategic improvements, maintains relationships with internal and external stakeholders, ensures a motivated, customer-oriented organization, and expands / shifts services as appropriate
* Accountable for developing prospective and retrospective risk adjustment review processes that are in compliance with all government regulations to drive accurate coding for Florida Blue Medicare in support of accurate risk capture; efforts will serve in partnership with FBM Stars and HEDIS quality programs
* Manages universal relationship strategy for multi-million dollar vendors relationships which includes performance management and process improvements to increase quality and efficiencies for risk adjustment strategies and revenue program management
* Oversees program governance and management, including evaluating existing operational operational metrics, developing new metrics as necessary, to better assess the performance of organization in achieving risk adjustment coding accuracy and mitigate compliance risks
* Lead, coach, and instruct process owners and improvement teams in the definition, documentation, measurement, improvement, and control of processes aimed at optimizing the Risk Score of the Medicare Advantage programs through Member and Provider Engagement initiatives
* Collaborates and coordinates with internal and external stakeholders to work through barriers, manages multiple competing priorities and resources, and influences activity both inside and outside of direct accountability
* Oversees Operations Support team which supports ad hoc and supplemental data and reporting needs to support all the operational units within RPM -- Prospective (member outreach and provider engagement), Retrospective (medical record review and provider auditing), and Operations units within RPM, including, but not limited to: quickly and easily organizing large data sets, quickly and easily creating, automating, and documenting operational processes for Retrospective and Prospective Risk Adjustment, reconciling large data sets and/or reports from disparate sources (e.g., reconcile vendor reports with internal data), for BI tools for risk adjustment interventions, updating data sets into BI tools, or otherwise extracting and filtering multiple files for campaign purposes, and critically reviewing the outputs from the tools, and actively participating in each operating team's strategic and tactical planning

Job Requirements:
* Related Bachelor's degree or additional related equivalent work experience
* 7 years related work experience. Experience details: Medicare risk adjustment
* 5 years direct supervisory/management experience

Preferred:
* Master's degree
* Green Belt of LEAN Level 1 certification
* Demonstrated knowledge of CMS practices, policies and regulations
* Experience with strategy development, execution, planning and management of high priority/high visibility projects related to corporate efforts.
* Experience working in a shared services matrix type organization

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, Short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan includes employer contribution and employer match;
Paid time off, volunteer time off, 10 holidays and two flexible Well-Being days
Additional voluntary benefits available; and
A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Annualized Hiring Range: $172,000 - $215,000

Annualized Salary Range: $172,000 - $279,500

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.