Executive Director Of Risk Adjustment
Eden Prairie , Mn, Us
Oversaw the Risk Division and owned end-to-end risk adjustment process, including the design of the annual coding program, all chart review (internal and 3rd party vendors), audits, physician education and compensation as well as suspecting and screening programs for Optum’s southern California region, including 16 IPAs and 5 acquisitions that included Quality & Risk performance.• Solved for and maximized profitability of all new acquisitions.• Managed a team of 8 direct reports and an overall department of 20 and engaged with other key internal and external stakeholders as the leader of risk.• Accumulated more than $950M in risk revenue with a network average RAF of 1.6. During tenure improved RAF by 20% and doubled IOI. • Business/process owner for risk adjustment.• Oversaw, coordinated, or performed data mining and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine strategies to achieve optimal performance. • Oversaw physician performance and outreach, nurse practitioner embedded and clinical programs, and home assessments.• Managed and optimized the end-to-end risk adjustment processes and identify risks and opportunities associated with current processes.• Maintained management oversight of the coding department.• Aligned vendor management including contracting and management of assessment providers, chart review vendors, data analytics and successor risk adjustment tools.• Planned for and initiated recoupment and revenue maximization of all acquisitions.• Analyzed business process information to identify key issues, trends, and root causes (e.g., training issues; lack of understanding by user community) that point to improvement opportunities.• Designed annual risk adjustment programs including but not limited to physician outreach, physician education, goal setting, and forecasting.• Worked synergistically with Quality, 5 Star, HEDIS and P4P departments.