Director, Medicare P&L Management

Employment Type

Full-time

Exempt or Non-Exempt

Exempt

Job Summary

• Hybrid Work Environment - Must reside in Hawaii**
  
  
  

Pay Range: $126,500 - $278,500

Note: Individuals typically begin between the minimum to middle of the pay range

The Director, Medicare P&L Management is responsible for the development, implementation, and evaluation of strategies and initiatives across the organization that contribute to the short- and long-term success of the financial goals for the Medicare line of business. The primary focus is on revenue optimization through performance management of the Medicare Stars program and ensuring Medicare risk-adjusted revenue accuracy. This position will oversee and lead the daily operations of the Medicare Stars and Risk Adjustment program, including data collection, intervention management, provider engagement, and compliance. HMSA strives to be a 5 Star MA plan which delivers exceptional quality, value and superior member service to our members. Achieving a 4 - 5 Star rating and maximum quality bonus payments from CMS is critical to maintaining our competitiveness in the MA market and enables us to deliver a strong clinical quality program as well as the best member experience through administrative excellence. Optimizing our risk score is also critical to the sustainability of the MA line of business. The role will work cross-functionally with other leaders across the organization to address cost trend drivers for the Medicare line of business.

Minimum Qualifications

• Bachelor's degree and ten years of health care related experience; or equivalent combination of education and related work experience.
• Five years of supervisory or management experience or related leadership.
• Experience leading diverse teams in matrix organizations.
• Demonstrated ability to manage and prioritize multiple projects, driving change and innovative thinking with continuous quality improvement in mind.
• Demonstrated ability to communicate effectively (verbal and written) with management and staff at all levels.
• Strong understanding of Medicare Stars, risk adjustment or MA program rules and requirements
• Intermediate working knowledge of Microsoft Word, Excel, and PowerPoint.
• Basic knowledge of Microsoft Outlook.
  
  
  

Duties And Responsibilities

• Program Leadership
• Function as the leader and champion of the Medicare Stars Program, risk adjustment operations, and Medicare cost of care initiatives.
• Collaborate with internal and external stakeholders to establish measure by measure targets for the 50 clinical, experience and administrative measures in support of the overall contract-level Stars goal.
• Develops targets for key operational metrics to drive improvement in risk score accuracy. Works with Finance to forecast risk scores for each contract, plan, and member segments.
• Develops and evolves the programs operating model, leveraging and defining responsibilities for internal resources, vendors, the provider network, provider enablement entities, and external partners to drive performance.
• Educates stakeholders, partners and vendors about Stars and Risk Adjustment program requirements and drive performance to meet expectations.
• Define and implement processes for monitoring key operational performance metrics and establish processes for managing vendor relationships, monitoring vendor performance, and provider performance.
• Maintains a deep understanding and educates stakeholders on CMS requirements and regulations related to the Medicare Stars Program, risk adjustment methodologies, coding guidelines, and operational best practices.
• P&L Strategy
• Builds and executes a strategy to achieve 4 star rating and reach annual benchmark for risk adjustment coding accuracy and quality, optimize cost of care, and maintain compliance with CMS regulations.
• Develops provider engagement and performance management strategies to close care gaps and enhance clinical documentation. Collaborates with leadership in finance, and provider network management to develop provider performance incentives, and value-based payment models for providers, physician organizations, health systems, and/or provider enablement entities.
• Align Stars activities and interventions with HCC risk adjustment initiatives to optimize care improvement opportunities with revenue management.
• Present updates on Stars performance and quality outcomes relative to the program strategy to executive leadership, staff, and other audiences as required.
• Analytics and Performance Management
• Develop and evolve analytic capabilities to support performance tracking, identify performance opportunities, diagnose drivers of underperformance, and provide actionable insights.
• Oversee the production of the Stars and Risk Adjustment performance dashboards which monitors and reports ongoing performance against targets; ensure ongoing analysis of performance at the contract level, the domain level and at the measure level; make recommendations to adjust goals and targets, as necessary.
• Develop process for tracking projected and realized savings associated with cost of care initiatives, in collaboration with Financial Planning and Analysis team. Tracks implementation status, risks, and financial assumptions for cost of care initiatives.
• Cross-Functional Integration and Communication
• Provide strategic oversight and direction to ensure development efforts for Medicare P&L management, clinical quality improvement projects, member experience improvement projects, and member and provider engagement activities are coordinated and aligned to support HMSA's performance goals. Coordinate and direct designated liaisons with the implementation of the operating plan, including leadership and staff from Provider Engagement, Provider Operations, Internal Operations, Medicare Programs, Health Management, Pharmacy Management, Finance, our drug PBM and other partners/vendors.
• Oversee internal cross-functional teams and external partner collaborations on P&L performance improvement activities.
• Management and Leadership
• Manage program staff in assignment of projects and work, performance management, career development, compensation, recruitment, training and development.
• Prepare and monitor unit plan and budget for area of responsibility. Review budget versus actual expenditures.
• Adjusts processes for both operational and strategic activities that are related to procedures, workflows, and other business activities that impact employee productivity and morale.
• Functions as a leader in Medicare Programs department and cross-functional leadership teams, helping to lead the department and organization toward meeting its goals, mission and vision.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.