Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

　　Position Summary

　　The Senior Director of Risk Adjustment Operations in our Health Plan is responsible the overall development, refinement, maintenance, monitoring and oversight of Medicare Risk Adjustment initiatives and operations. The Senior Director is also responsible for all aspects of the decision-making and implementation of medical record coding reviews and coding policies for the organization.

　　The Senior Director is expected to lead the risk adjustment operations and strategy around improvement opportunities for clinical provider training, and medical record documentation. Working closely with the Health Plan's Risk Adjustment Data Analytics and Data Architecture team on data gathering, suspect identification, and health plan reporting, the Sr. Director is responsible for the mission-critical function of building and monitoring audit functions.

　　Job Description

　　Key Outcomes:

　　Ensures development, implementation, and maintenance of policies and procedures to support all operations processes & procedures and monitoring adherence.

　　Develops, trains and mentors staff members.

　　Oversees the day-to-day coding team tasks to ensure that accurate and complete coding is performed by all company employee, partners, and vendors.

　　Complies with Risk Adjustment regulatory rules.

　　Partners with compliance and finance to ensure compliance with CMS rules and regulations in order to prepare for RADV audits.

　　Escalates gaps and risks (both operational and compliance) in projects to senior management when identified.

　　Participates in CMS user group calls and regional meetings

　　Develops and implements chart pull strategy and analysis for chart review including vendor identification and selection.

　　Actively participates with Network team to give training and feedback on risk adjustment to providers.

　　Manages vendor contracts and looks for most effective ways to use vendors and/or build internal knowledge/use internal resources.

　　Creates planning timelines and resource requirements; works with staff and Analytics to determine dollars at risk.

　　Facilitates the development of tracking and monitoring mechanisms for projects.

　　Collaborates with the Stars Leaders to ensure appropriate integration of workstreams and ultimate delivery on company strategies.

　　Contributes to the achievement of company goals and objectives by performing other duties as assigned.

　　Communicates and interacts effectively and professionally with co-workers, management, customers, etc.

　　Education/Experience

　　Bachelor’s Degree

　　10 years of experience in health care, managed care, health insurance or strategic consulting

　　and healthcare payment and coding methodologies (i.e. ICD-9, CPT, DRG and HCC coding)

　　Leadership/management experience required

　　Workflow analysis experience

　　Experience managing vendor relationships to improve and optimize and service levels.

　　Experience leading and formulating strategy with the ability to build strong connections with people and teams in all environments (internal, external, government).

　　Experience leveraging knowledge of the external market, competition and regulatory environment to create value for the enterprise.

　　In compliance with MPHC’s Department of Defense government contract, any/all persons hired for this position will need to verify their US citizenship and complete the required employment eligibility verification upon hire. ​

　　Required License(s) and/or Certification(s):

　　CPC Certification Requirement:

　　In compliance with MPHC’s Department of Defense government contract, any/all persons hired for this position will need to verify their US citizenship and complete the required employment eligibility verification upon hire.

　　We are an equal opportunity/affirmative action employer.

　　Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]

　　Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit https://careers.martinspoint.org .