Risk Adjustment Manager, Provider Engagement

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At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We’re excited to share Blue Shield of California has received awards and recognition for â€" LGBT diversity, quality improvement, most influential women in corporate America, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we’re striving to make a positive change across our industry and the communities we live in â€" Join us!


The Risk Adjustment Manager, Provider Engagement will coordinate implementation of Blue Shield Programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines. The ideal candidate possesses field-based team management, excellent customer service skills, project management skills, organizational skill, analytic skill, self-starter and high attention to detail. May be responsible for assembling a project team, assigning and monitoring work of team members and providing guidance and leadership.

Job Summary
  • Ability to strategically lead in a manner that ensures the RA Team works with Provider Groups to ensure accurate diagnostic coding and improvement of risk adjustment scores (RAF).
  • Provides direction to RA Team to drive improvements in support of their risk adjustment processes through developing comprehensive, provider specific plans to increase their RAF performance, improved their coding specificity with Provider Group consultation.
  • Provides direction to RA Team in assisting Provider Groups in understanding the CMS-HCC Risk Adjustment as it relates to payment methodology through their claims/encounter submissions and the importance of proper chart documentation of procedures and diagnoses coding.
  • Provides guidance to RA Team in assisting Provider Groups in understanding Medicare Stars quality and incentive programs utilizing analytics and identifies and target providers.
  • Establish positive, long-term, consultative relationship with Providers.
  • Utilize analytics and identifies targeted providers for Medicare Risk Adjustment training and programs through routinely consulting with Providers to clarify missing or inadequate information to determine appropriate diagnostic and procedure codes.
  • Implementation of clinical education materials and initiatives related to risk adjustment activities, HEDIS measures, and any appropriate gaps of care.
  • Provides guidance to ensure member encounter data submissions (services and disease conditions) are being accurately documented and relevant procedure codes as well as all relevant diagnosis codes are captured through encounter and claims data.
  • Reviews analysis to forecast and evaluate the performance of the BSC Risk Adjustment Programs and refine annul risk adjustment strategies to achieve optimal performance.
  • Performs analysis and provides formal feedback to Provider Groups on regularly scheduled basis through developing and delivering materials, coding tools and actionable reporting.
  • Manages provider engagement relationship with measurable, actionable, solutions to Provider Groups that will result in improved documentation accuracy and submission practices.
  • Provides guidance to RA Team in assisting in collecting charts where necessary for analysis.
  • Collaborates with providers, coders, facility staff and a variety of internal and external personnel on wide scope of Risk Adjustment and Quality education efforts.
  • Communication to external parties and/or leadership to present financial/clinical metrics and facilitate their engagement in programs.
  • Manages End-to-end cross-functional project management.
  • Knowledgeable about healthcare-related governmental regulations, procedures, and requirements. Continuous learning as additional information is released.
  • Special project as assigned.
  • Some travel required.


Knowledge and Experience
  • Requires minimum of a bachelor's degree in Healthcare Administration, Business Administration or equivalent combination of experience and education.
  • Requires a minimum of 5+ years of healthcare industry experience, with a thorough understanding of provider relations, clinical metrics, claims/encounters and analytics.
  • Requires a minimum of 3+ years of managing field-based teams.
  • Candidate has knowledge of ICD-10, Risk Adjustment, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management and/or provider network management areas of a healthcare-related company.
  • Candidate has had 3 years' experience facilitating meetings and presenting program education, metrics and results to external parties or internal leadership.
  • 2 years of developing analytic reporting analytic insights into RAF improvement and business/financial challenges.
  • Proficient in Excel, Word, PowerPoint, and Outlook.

Physical Requirements

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
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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.
COVID-19 update: From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a federal contractor and a health care company, Blue Shield requires all employees to be fully vaccinated prior to start date as a condition of employment and provide proof of vaccination status. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date
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