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Medicare Risk Adjustment Program Specialist, South San Francisco, CA

Health Plan of San Mateo


South San Francisco, CA

January 24, 2017


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Medicare Risk Adjustment Specialist to work across departments and with external stakeholders to enhance clinical quality and coordinate operations to manage, optimize, and measure Medicare data revenue. Specifically, the Program Specialist will manage new and ongoing projects, develop educational programs, perform data analysis, make programmatic recommendations and collaborate with other departments to ensure compliance with Medicare coding and documentation requirements. The Program Specialist will work with all CareAdvantage lines of business with the working knowledge and context of HPSM’s other lines of business. The essential duties and responsibilities will include the following areas:

  • Project Management: Coordinate Program projects, as needed and appropriate. Contribute to the development and maintenance of project plans and operational documentation; proactively identify problem areas and propose recommendations or solutions. Analyze data for the purposes of project coordination and project monitoring, both during and at the close of projects. Contribute to development of the annual risk adjustment strategy.
  • Data Submission: Maintain up-to-date knowledge of Medicare Advantage data submission processes and timelines as relates to program activities. Assist with identifying root causes and troubleshooting data submission issues at the organization, provider, and regulator levels.
  • Analytics & Reporting: Assist with development of new or revision of existing reports reflecting risk adjustment metrics or opportunities at the patient, provider, and population levels. Monitor existing reports and identify performance indicators, key metrics and influencing factors. Perform data analysis, create reports or presentations, and deliver reports to end users, as appropriate.
  • Vendor Coordination: Responsible for coordinating operations of vendor assessment and other outsourced projects. In close coordination with the Program Director, track and document ongoing vendor work, identify opportunities for improvement, and plan and implement auditing projects, data analysis projects, and other outsourced risk adjustment projects, as needed. Establish and maintain relationships with key risk adjustment vendors.
  • Compliance with Coding & Documentation Requirements: Maintain up-to-date knowledge of Medicare Advantage risk adjustment regulations and guidelines. Coordinate regular and ad hoc documentation reviews and audits for coding & documentation quality assurance and predicting or mitigating financial risks related to regulatory audits. Develop and maintain Risk Adjustment Data Validation (RADV) audit project and communication plans, desk procedures and resources.
  • Communication: Represent HPSM effectively and appropriately with all internal and external customers by utilizing subject matter expertise and strong customer service skills. Ensure consistent and effective communication across internal and external stakeholders, including, but not limited to: Quality and Health Services, Finance, Claims, Provider Services, Informatics, Business Systems Integration, Member Services, IT, Compliance and Regulatory Affairs, risk adjustment vendors, network providers, and other health plan and advocacy partners.
  • Training & Tools: Design and develop risk adjustment training programs and tools. Identify internal and external training opportunities and coordinate implementation of trainings and tools.
  • Workflows and Desk Protocols Development: Support development or revision of current policies and procedures, operational workflows, and desk procedures relevant to program operations.
  • Other Duties: Participate in other organizational initiatives and projects, as assigned. Participate in regular work group and management committee meetings, as needed. Contribute to team effort by accomplishing related tasks, as needed. Develop and maintain professional and technical knowledge by reviewing relevant publications, forming peer networks, and attending educational workshops, as appropriate.


Education and Experience: Bachelor’s Degree in Healthcare Management or Policy, Public Health, Public or Business Administration, Finance, or related field required. Master’s Degree preferred. Minimum 1-2 years direct work experience (operations, healthcare or managed care environment preferred). Demonstrated interest in public health, health policy, care delivery, and state and/or federal managed care programs.

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Visio and PowerPoint. Medicare and Medi-Cal (Medicaid) managed care programs a plus.

Ability to: Take personal initiative and work independently, as well as part of a team. Adapt to manage changes in project or business requirements. Continuously re-prioritize to accommodate new or specialized tasks. Master new business and health care content and employ subject matter expertise. Work creatively and with great attention to detail. Communicate effectively, both verbally and in writing. Utilize strong interpersonal and customer service skills. Deploy formal project management techniques and tools, including project charters and plans.

Starting Compensation Range: Between $74,440 - $96,600 – depending on experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

Application Process: To apply, submit a resume and cover letter (required) with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: careers@hpsm.org or via fax: (650) 616-8039. File by: Continuous until filled. EOE


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