Senior Director, Government Revenue (Risk Adjustment Analytics)

We have an exciting opportunity for the Senior Director of Government Revenue to join our leadership team at the UPMC Health Plan.  As Senior Director, you will lead the risk adjustment analytics function.  The selected candidate can work remotely from anywhere in the US.  If this sounds like an opportunity that meets your interests, we invite you to learn more and apply today!

The Senior Director, Government Revenue is responsible for providing risk revenue financial services, strategic proposals, and strategic programs in support of the Medicare Advantage products, Medicare Special Needs products, and the Affordable Care Act (ACA) Marketplace programs This position plays an analytic leadership role in achieving the strategic and operational objectives of the Risk Adjustment Department including optimizing UPMC Health Plan’s receipt of earned risk-adjusted revenue for all risk-adjusted segments (i.e., Medicare and the Affordable Care Act Commercial segments) and enable improved accuracy in understanding the illness burden of our membership to better manage their risk, care, and health. 

This position leads an Analytics team responsible for delivering insight used to optimize risk adjustment revenue and improve the quality of health care delivered to UPMC Health Plan members. This work includes leadership to develop and support the following: situational awareness of risk adjustment optimization opportunities; target identification to close suspected and actual gaps in coding and care delivery; predictive analytics and theory testing to inform risk adjustment optimization activities; provider profiling to enable care system and clinical risk adjustment improvement; support for intervention design and results, including ROI; and reporting at various levels. This position requires knowledge of industry-leading statistical, information technology, analytic, and data science methods to identify interventions and management opportunities that optimize risk adjustment revenue across multiple lines of business. 

The Senior Director requires significant interaction with leadership at all levels of the organization, including internal and external customers.  They will work collaboratively and cross-functionally with Commercial Sales, Marketing, Product Development, Pharmacy, Enrollment, Government IT and Finance in supporting the sales lifecycle and evaluation of commercial Marketplace products.

This position will manage employees, including skill and career development, policy administration, discipline, employee relations, goal setting, and performance reviews and will report to the VP, Risk Revenue Operations.

Responsibilities:

• Lead a team to apply sound data science, analysis and reporting, and program evaluation practices to support risk adjustment optimization across Medicare, and Exchange populations in the following areas:
  • ERA Program Analytics: Answers the question of whether we are focused on the right members, the right types of gaps in coding and care, how much we have accomplished, what opportunities remain, and estimates the value of those opportunities to drive risk adjustment strategy and meet our revenue targets. 
  • Intervention and Pilot Test Analytics: Analytic and measurement support to inform pilot test/intervention design to ensure rigor in outcomes evaluation; evaluate pilot tests/interventions for gap closure and ROI; and inform decisions about pilot/intervention modification and scale-up.
  • Provider-Focused Analytics: Analytic and reporting support to understand provider performance on gaps in coding and care delivery and enable provider coaching.
• Provides strong leadership to the Risk Adjustment Analytics team, including building a successful team, developing strategic partnerships, and influencing across UPMC Health Plan’s highly matrixed organizational structure to represent risk adjustment interests.
• Maintains and develops knowledge of industry-leading analytical and strategic planning methods used to detect opportunities to increase healthcare outcomes and maximize revenue through risk adjustment optimization. As appropriate, include analysis related to reducing health care costs, improving member experience, and improving member health to be attentive to the Triple Aim.
• Stays abreast of changes in the rapidly-evolving health care marketplace, including changes to the Risk Models, and understands how trends, competitors, external context, and internal dynamics shape opportunities and challenges for Risk Adjustment. Uses knowledge to inform, guide, and refine strategic direction that will maximize UPMC Health Plan’s ability to achieve its risk adjustment revenue targets.
• Effectively communicates complex risk adjustment concepts, strategies, initiatives, analytics, and results to a variety of stakeholders, including senior staff and executive leadership.
• Understands the strategy and future direction of Blue Cross, as well as the challenges and opportunities that are inherent to that strategy and direction. Ensure that the team priorities reflect the company’s strategic direction, and ensure the team’s knowledge, skills, and ability are adequate to meet current and evolving needs for risk adjustment optimization.
• Directs the team, including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.
• Own the Government Revenue process. This will require working diligently with the consulting organizations, Sr. Management at UPMC, Operational/Organizational leaders in the Medicare, SNP, and ACA Exchange areas.
• Responsible for creating partnerships with medical leaders within UPMC Health System to develop programs that will increase the revenue for UPMC Health Plan and UPMC Health System.
• Responsible for creating partnerships with physician leaders within the community to develop programs that will increase the revenue for UPMC Health Plan.
• Own the relationship with various vendors used to increase revenue at UPMC Health Plan. 
• Ensure all processes and activities are following State and Federal requirements.
• Required to present to information to Sr. Physician Leaders at UPMC and other practices within UPMC Health Plan service areas
• Among the factors management will consider in measuring performance of the Sr. Director will be the:
  • Accurate Analysis of current procedure plus projections of future revenue
  • Quality of the process and procedure improvements the employee recommends
  • Creativity and thoroughness of the analysis and improvements.
  • Meeting the deadlines set forth by CMS and Senior Management for various products.
  • Implement additional revenue-generating programs for HCC.
  • Project new membership and revenue possibilities associated with a new cohort. Project revenue possibilities with physician practices and their historical data.
• Establish mechanisms to monitor product operations, utilization, cost of services, and enrollment. Review reports and identify trends that may impact the success of the product. Monitor progress against budget and provide recommendations when trends are noted. Work with VP and COO to implement changes
• Support the enrollment/sales strategy of Commercial Sales to meet projected enrollment for the Exchange products. Oversee the ACA product filing submission process to monitor that timelines are met, instructions followed, and approvals obtained by all stakeholder teams. 
• Collaborate with the Senior Director, Risk Adjustment Revenue & Education regarding the Risk Adjustment Data Validation (RADV) audit oversight program, including data quality assessment and submissions.