Kirk Shanks Email & Phone Number

Kirsha, LLC is a healthcare risk adjustment solutions provider specializing in MAPD risk adjustment consulting, financial analysis, operational analysis, and data management.

New York, Ny, Us

In this role I was able to reach a number of career highlights. I mimicked the HHS-OIG audits for targeted reviews of specific diagnosis codes for a large regional MAPD health plan. I served as interim risk adjustment program supervisor while advising an at-risk MSO on a complete risk adjustment program redesign. This MSO was near financial default, and we returned it to profitable path.I worked with a few different at-risk MSOs and MAPD plans on due diligence efforts for potential investors and buyers.I helped develop and implement an analytics package based upon prescriptions associated with certain diseases. We were able to discover approximately $10 million in lost annual revenue for one region for a large national carrier.I have assisted an at-risk provider group/MSO since 2019 with evaluation and analysis of their risk adjustment program, helping them to reduce dropped chronic diseases year over year, while increasing compliance by identifying acute diseases that were incorrectly refreshed (most should've been "history of"). We have also been able to accurately predict accruals for financial reporting, and calculate ROIs for chart review vendors.

Work closely with Medicare Advantage and Part D health plans to manage risk adjustment factor (RAF) product development and accurately calculate how much money clients will receive from the government.Routinely define RAF performance reports and work closely with and educate client leadership, implementing programs and making recommendations. Create all corporate policies and process flows. Define requirements for payer and electronic medical records (EMR) data integration, develop algorithms to deliver patient-specific suspect HCC medical conditions, and reconcile with risk adjustment processing system (RAPS).* Developed innovative software that improved efficiency and accuracy in calculating Medicare receivables.-- Positioned client companies to save $50,000+ annually by reducing headcount--without installing software, allowed clients to upload gigabytes of data to the Web and quickly download spreadsheets with results.-- Program delivered calculations that used to take 2 or 3 days in just hours and enabled companies to automatically calculate receivables for multiple health plans concurrently.-- Improved reliability of forecasting and reporting by eliminating the potential for human error.* Improved the accuracy and efficiency of the CMS bidding process by developing an algorithm that provided a simplified overview of data for use by health plans and actuaries; grouped multiple lines of data for individuals by episode and type, enabling large amounts of information to be easily parsed for improved decision making.* Audited a MAPD chart review process at the request of the Florida Office of Insurance & Regulation.

Fort Lauderdale, Fl, Us

I was responsible for the execution and oversight of risk adjustment consulting services for both managed care and provider practice clients. With demonstrated and proven success within Medicare Advantage and Commercial Exchange risk adjustment program operations, I provide Gorman Health Group (GHG) clients with a broad range of consulting services related to: End-to-end risk adjustment operations, program, and data mapping/integration. Risk adjustment vendor selection, implementation, and quality oversight. Retrospective and prospective program design, implementation, and oversight. Design and oversight of Hierarchical Condition Category (HCC)/clinical documentation operations, quality oversight, education, and analytics. Financial management, forecasting, and integration across the managed care enterprise. Comprehensive program integration to align with corporate initiatives to drive quality improvement and medical trend management. Comprehensive provider education and engagement strategies. Risk Adjustment Data Validation (RADV) and overpayment recovery mitigation and preparedness strategies. Federal and regulatory policies and procedures related to risk adjustment.

Princeton, New Jersey, Us

I was responsible for owning and driving Indegene's product strategy for healthcare analytics products (e.g. risk adjustment) in the payer space. My other responsibilities include:- Leading client conversations and participating in pitches along with the sales team and providing subject matter expertise for the Medicare, HIX, and Medicaid marketplace.- Support for the tracking and reporting for all assigned business activities and opportunities pertaining to the risk adjustment product lines and delivery for emerging opportunities and new markets.- Participating in the strategic development initiatives to identify emerging product opportunities and system enhancements which may expand product markets, improve client appeal, process flow, and overall business function, industry reputation, and financial performance.- Serving as an ambassador to the market as a participant in business and industry meetings with current emerging accounts and relationships.- Establishing myself as a market expert through developing deep knowledge of the payer market and key developments in the health plan risk adjustment market.- Working with the product development team to provide industry and market expertise.- Working with the operations and delivery team where required to deliver solutions to the customers.

Columbus, Ohio, Us

Plan, organize, monitor, supervise, and maximize opportunities related to revenue streams using analytics to identify trends and opportunities for improvement. Calculate revenue projections and ROI, working with vendors. Ensure compliance with Centers for Medicare and Medicaid Services (CMS), Ohio Department of Insurance, and other regulatory agencies. Serve as primary contact for annual Medicare Advantage bid process. Monitor all factors, including risk adjustment factors, and impacting capitation payments from CMS. Routinely coordinate CMS audits and serve as a subject matter expert in Medicare Risk Adjustment.

Tampa, Florida, Us

Hired as an actuarial analyst and promoted in 2007. Managed the full scope of data projects that included Medicare Part D reconciliations, Medicare CMS-HCC, CMS-RxHCC risk adjustment models, Retiree Drug Subsidy (RDS) program, Medicare MA-PD bids, and Medicare 5% Limited Data Set.Worked closely with clients, typically CFOs and CEOs as the company's primary customer-facing representative. Obtained the majority of client data, uploaded it into databases, and processed raw data into usable data. Wrote algorithms for Part D reconciliation and risk adjustment, as well as ad hoc projects. Routinely trained other actuaries and actuarial analysts.* Enhanced efficiency, speed, and accuracy by creating business process flows that were adopted companywide.* Standardized and automated process for plan benefit package (PBP) claims mapping and risk scoring--created algorithm and comprehensive, multiple-year database that could be easily accessed for the entire U.S.* Designed, automated, and implemented extraction, transformation, and loading (ETL) process for all CMS standard data sets, including monthly membership reports (MMRs), risk adjustment processing (RAPS), prescription hierarchical condition coding (RXHCC), and CMS Medicare bids.* Designed all algorithms to process data using business rules in conjunction with technical definitions (i.e. data dictionaries).* Significantly reduced time for prescription drug event (PDE) reconciliation--cut it from a week to an hour.

While pursuing graduate degree in actuarial science, received a mathematics assistantship that covered tuition costs in exchange for working in the mathematics lab for 10 hours a week.

Seattle, Wa, Us

Developed databases that enabled beneficiaries' claims data to be uploaded and transformed it into clean, usable data sets that people could put into Excel spreadsheets and easily manipulate. Estimated incurred but not reported claims revenue (IBNR) using reserve models.* Developed training materials for an underwriting manual that company sold to health plans.

Atlanta, Ga, Us

Completed one year toward Ph.D. in Mathematics.

Houston, Texas, Us

While completing undergraduate degree, designed internal websites tied into Access databases. * Gained recognition as an internal subject matter expert on creating internal websites to manage projects.

Led a staff of 70 to 100 employees as one of 4 managers.

Master Of Actuarial Science, Actuarial Science

Bachelor Of Science, Mathematics

Other; Certificate In Entrepreneurship Essentials