Director, Medicare Risk Adjustment

Reporting to our CFO, the Director of Risk Adjustment coordinates and monitors all aspects of San Francisco Health Plan's risk adjustment programs. Responsibilities include developing and overseeing all risk adjustment activities at San Francisco Health Plan (SFHP), overseeing any vendors used for risk adjustment, ensuring compliance with all regulatory guidance for risk adjustment activities, developing and directing execution of reporting on risk adjustment goals and targets, and representing risk adjustment functions within SFHP.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

Salary: $170,000 to $210,000 annually

WHAT YOU WILL DO:

• Oversee risk adjustment activities for Medicare Advantage, Affordable Care Act (ACA) and Medi-Cal.
• Provide leadership to ensure alignment between the business functions and Risk Adjustment Compliance.
• Develop, implement, and manage programs related to risk adjustment including HCC/diagnosis code accuracy, diagnosis code submission, and Risk Adjustment Data Validation (RADV) Audit.
• Monitor and refine existing risk adjustment programs.
• Oversee any risk adjustment vendors including developing a robust routine oversight process and performance reporting. Work with the vendor management team to have routine vendor meetings where performance reporting is discussed.
• Minimize risk by staying current on regulations, assess and analyze their significance and impact, and recommend policies to ensure compliance.
• Stay up to date with industry changes and trends including Federal Risk Adjustment cases, and provide awareness to compliance, legal, and business owners on potential risks, issues, and policy enhancements.
• Develop and direct internal risk adjustment compliance initiatives, audit and monitoring activities (e.g., risk assessment, audit work plan development and execution, audit readiness activities, etc.)

WHAT YOU WILL BRING:

• 7+ years of Medicare Risk Adjustment experience.
• 7+ years of project leadership experience.
• 5+ years of management experience.
• Knowledge of and experience with state and federal insurance programs.
• Experience managing vendor relationships.

WHAT WE OFFER:

• Health Benefits
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

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