What are the responsibilities and job description for the Risk Adjustment Compliance, Sr. Principal position at Blue Shield of CA?
Your Role
The Risk Adjustment Compliance team plays a critical role in ensuring that Blue Shield maintains appropriate adherence to federal and state regulations. The Director, Risk Adjustment Compliance will report to the Senior Director, Government Programs Compliance. In this role you will provide strategic leadership and management of the department overseeing compliance with regulations and laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare lines of business, which includes implementation of elements of an effective compliance program. You will oversee the development of risk assessments oversight and the monitoring of work plans pertaining to Risk Adjustment and partner with business areas to ensure and implement effective prevention, detection and correction of compliance issues.
Your Knowledge and Experience
Requires a bachelor's degree in business administration, Public Policy, Public Health, Health Administration, related field, or equivalent experience required.
Master's Degree CPA, CISA, JD, MHA, MBA, MIS or equivalent experience preferred
Requires 10 years compliance experience, with increasing responsibility for risk adjustment coding or related compliance functions in a health plan environment, with CMS, DHCS, and state Medicaid/Medi-Cal regulations
Requires at least 6 years of management experience as a people leader with direct reports.
Requires proven experience with RADV audits, prospective and retrospective chart reviews, encounter data, claims submissions, OIG investigations, False Act implications, and provider education
Requires deep understanding of CMS-HCC, CDPS Rx, and ACA risk adjustment models
Requires solid understanding in ICD-10, CPT, and HCC coding
Requires familiarity with RAF (Risk Adjustment Factor) calculations and their financial implications
CRC, CCS, RHIT or similar coding certifications required, HCCA certification (CHC) or equivalent preferred
Requires demonstrated ability to lead and influence in a large matrixed organization, and experience working with senior executives
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.