Director, Risk Adjustment

About Our Company

At Altais, we're looking for bold and curious innovators who share our passion for enabling better health care experiences and revolutionizing the healthcare system for physicians, patients, and the clinical community. At Altais, we’re building breakthrough clinical support tools, technology, and services to let doctors do what they do best: care for people. We invite you to join our growing passionate team as we change the game for the future of healthcare and enable the experience that people need and deserve. Altais family of companies include: Brown & Toland Physicians, Family Care Specialists and Altais Medical Groups.

About Your Team

Are you looking to work with a high performing, fast growing and dynamic Risk Adjustment Team? We are 4,000+ physicians, working in over 40 cities throughout California, caring for more than 500,000 patients. If you are passionate about reshaping healthcare and want to work for a mission driven organization where new ideas and innovation are valued, then we would like to meet you.

About Your Work

As the Director, Risk Adjustment you will be responsible for ensuring the organization has a comprehensive, efficient and compliant documentation integrity program (risk adjustment and HEDIS/Stars Quality measure documentation). Works directly with clinicians, certified coders, IT, enterprise analytics, network management and physicians. Owns accountability for ensuring our members’ medical record is complete, accurate and represents accurate member conditions. This role will work closely with the Quality/Accreditation teams, Customer Service and Call Center Teams, Provider Services Team, Nurse Practitioners, and Clinical Program Teams.

You will focus on:

• Applies in-depth knowledge of risk adjustment methodology to partner with key stakeholders in improving outcomes
• Oversees programs aimed at monitoring, oversight and compliance for coding accuracy
• Provides leadership and direct support for medical documentation integrity programs across all lines of business
• Ensures that documentation integrity programs comply with all applicable federal and state guidelines
• Deploys programs to ensure members’ medical record is complete, accurate and represents accurate member conditions
• Leads the design of a high performing, compliant documentation integrity program including leading analytical and operational teams for successful delivery of programs including:
• Deploying a comprehensive coding and documentation program
• Retrospective and prospective chart review
• Abstraction and encounter submission
• Provider profiling, engagement and education programs
• Annual Health Assessment programs
• Ensures the appropriate strategy, tactics and data capture processes are in place and in compliance with state and federal regulations
• Participates and manage all regulatory audits
• Develops and implements provider education strategies and tools, monitors provider performance, develops improvement plans and assists physicians/care teams to ensure patients are accurately assessed for medical conditions
• Engages with enterprise functional areas to ensure Members with complex/chronic conditions are referred to care management programs
• Composes and distributes education materials to physicians and vendors to aid the collection of complete and accurate member profile documentation
• Stays informed of all risk related program requirements from CMS and develop implementation strategies to CMS requirements
• Oversees implementation of documentation integrity analytics platform and related technological solutions, including Epic integrated tools
• Creates a culture focused on Compliance
• Provides ongoing updates and policy modifications distributed by CMS
• Serves to alert relevant stakeholders and propose new operational policy/processes to comply with regulatory mandates

The Skills, Experience & Education You Bring

• Bachelor’s degree required.
• 10 or more years of related experience required.
• 5+ years of experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.
• 5+ years of experience in risk adjustment and HEDIS/STARS (Medicare Advantage/commercial).
• 5+ years of experience with Chart Review, In Home assessment, Provider education, Prospective programs and encounter submissions; knowledge of billing rules and systems
• 6 years of management experience required.
• 5 years of demonstrated experience with reporting and analytical tools (power BI, Tableau, etc)
• Experience driving results and influencing across a wide array of stakeholders Risk Adjustment experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.
• Knowledge within RAF markets (Medicare Advantage/commercial).
• HEDIS/STARS data abstraction and reporting experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.
• Chart Review, Annual Health Assessment (AHA/AWV), Provider education, Prospective programs and encounter submissions; knowledge of billing rules and systems
• Management experience and ability to be a servant leader who rolls up their sleeves to both do the work, coach the team, and be a strategic thinker to drive the program forward
• Deep analytical skills to leveraging data to formulate insights and drive decisions. This includes manipulating and understanding data to craft data-driven messages, as well as thinking of new ways to draw insights from data.
• Use data to explain the why and hold other leaders accountable.
• Strong skills in influencing without authority
• Expert at building relationships with a broad range of internal and external stakeholders.

Preferred Experience:

• 10+ years in Managed Care RAF/Medical Economics/Enterprise Analytics
• Certified Coder

You Share our Mission & Values

• You are passionate about improving the healthcare experience and want to be part of the Altais mission.
• You are bold and curious - willing to take risks, try new things and be creative.
• You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
• You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
• You co-create , knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.
• You build trust with your colleagues and customers by demonstrating that you are someone who values honesty and transparency.

Altais values the contribution each Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience within the job or the industry. The pay scale listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this job description. Additional pay may be determined for those candidates that exceed these specified qualifications and requirements. We provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.

The anticipated pay range for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, and experience.

Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.

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 workday.

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.