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   Current UPMC employees must apply in HR Direct

Senior Director, Risk Adjustment Government Revenue & Education


Shape the world of health care by joining UPMC!  As a leader in the industry, we are committed to enhancing the lives of all who are a part of our community.  Without our employees, we would not be able to innovate health care for our patients and health plan members. From hospitals to our corporate office, all UPMC employees impact our mission of creating life-changing medicine. To continue our tradition of excellence, we are in search for a Senior Director, Risk Adjustment Government Revenue & Education.

The Senior Director, Risk Adjustment Government Revenue & Education is responsible for the overall success of the retrospective risk adjustment coding department, inclusive of both on and offshore operations, the prospective risk adjustment program including oversight of all clinical and coding product developments with the Lumanent suite of products utilized by HSD physicians and coders, as well as the physician education program related to risk adjustment coding inclusive of chart/claims review, auditing and overall education of the entire UPMC Health Plan physician network for Medicare Advantage products, Special Needs products and Marketplace (QHP) products.

The position incumbent will oversee Retrospective Coding (on/offshore), Quality Review/Audit Coding, Physician Educators as well as serving as liaison to critical vendors and a key stakeholder in multidisciplinary committees with physician leaders and IDFS executives. The position is responsible for managing 45 employed staff and 37 contracted staff (80+ individuals) along with vendor partners. The position may need to market products created by other companies within UPMC. This position is under the guidance of the Associate Vice President, Government Revenue, and is responsible for the overall success of revenue maximization and regulatory compliance valued at $2.6B of Medicare/SNP risk adjustment revenue and Marketplace (QHP) revenue currently valued at $1.3B.

This role has the opportunity to be fully remote.  The ideal candidate will be an RN who is a dynamic leader with prior experience in medical coding.


  • Innovate additional opportunities for revenue maximization while maintaining compliance through relationships (new or established) both internally and externally. Report these opportunities for validation and review to UPMC executive leadership.
  • Work with current partners (vendors/UPMCE, etc.) on development of new applications, technology, or process to solve business needs related to risk adjustment practices while working within regulatory and technical constraints. Identify areas of improvement for existing technology and ensure enhancements and/or fixes are implemented.
  • Lead cross-functional vendor/IDFS meetings to ensure the efficacy of vendor products and ROI is realized for multiple initiatives such as Lumanent Point of Care and Post Encounter. Make recommendations as necessary to AVP, Government Revenue for expansion and commercialization of these products.
  • Serve as consultant/expert and final review for all coding rebuttals internally. Direct contracted consultant (AAPC) for any coding review requiring external 3rd party review and communicate those results internally.
  • Assist AVP, Government Revenue to drive performance, report results, and feedback regarding both the Lumanent Point of Care and Post Encounter products as well as the prospective provider education program. Collaborate on appropriate metrics for HCC capture and align with peers for the development of the program. Deploy education efforts within the UPMC Health Plan provider network to increase provider knowledge and awareness of risk adjustment and how it impacts business.
  • Network nationally and follow industry trade groups to identify any areas of opportunity to improve retrospective coding operations beyond current practice within regulatory guidelines. Make recommendations to superiors and staff as necessary. Ensure the department is meeting productivity metrics and devise corrections if necessary.
  • Collaborate with peers for the ongoing development of the HCC Provider Campaign.  Provide suggestions based on trending reports and feedback while innovating new ideas for the program, including introducing a Specialist Campaign valued at $5.9m. Network nationally and follow industry trade groups to understand what other payors do in this space to improve internal processes if needed. Ensure trending reports are available and productivity metrics are met and devise corrective actions if necessary.
  • Participate in the redesign of the HCC provider campaign related to the Lumanent POC application and provide ongoing feedback on the relevance and accuracy of reporting. Mitigate compliance risk by directing the chart/claim reviews and audits, developing mechanisms for reporting and trending while collaborating with peer groups. Make recommendations to executive leadership for both redactions and additions of codes for the CMS Submission process.
  • Responsible for the success of all regulatory audits, including but not limited to CMS RADVs for both Medicare and ACA, OIG audits, etc. Manage a team of quality coders to review all research and review all documentation and oversee the upload to CMS for review. Participate in all meetings and interim review findings related to the audits and communicate results to executive leadership. Implement any corrective actions as necessary.  Responsible for creating partnerships with medical leaders within UPMC Health System and Health Plan to develop programs that will increase the accurate capture and documentation of HCC conditions reflecting revenue for UPMC Health Plan and UPMC Health System. Likewise, leverage these relationships to identify inaccurate conditions to remove from CMS Submissions.
  • Assist AVP, Government Revenue with administrative budget valued at $12.6m (2020), and staff development as needed. Directly responsible for vendor contracts related to coding, audits, and consultants valued at $2.5m. Oversee risk adjustment coding operations acting as TPA and providing retrospective coding/audit review and overall consultation to contracted ACA and MA plans nationally.
  • Maintain current industry knowledge and trends, including but not limited to participating in educational events, acquiring certifications, and participating in committee work as appropriate. Ensure all processes and activities comply with State and Federal requirements
  • HOW PERFORMANCE WILL BE MEASURED: Among the factors management will consider in measuring the performance of the Sr. Director will be the: Efficiency of Government Revenue; Accurate Analysis of current procedures 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 and requirements set forth by CMS and Senior Management for various products.


  • A Bachelor's degree in business, mathematics, statistics, health care, nursing, management, or a related field coupled with a minimum of ten years of experience in the various fields of government revenue is required.
  • Master's degree in health, business, or a related field preferred or equivalent experience.
  • Ten years of progressive management experience is required.
  • RN highly preferred.
  • Coding certification preferred.
  • Must be able to manage a diverse set of staff both professional and non-professional.
  • The ideal candidate will have experience and an understanding of coding, physician negotiations/relationship building, historical HCC strategy implementation, and be familiar with HCC analytics.
  • Experience in health care insurance and the health care industry is preferred but those with relevant experience in other industries would be considered.
  • Strong computer and communication skills are a given, with expert knowledge in Excel, Word, PowerPoint, and other Microsoft software packages.
  • Person must demonstrate a high degree of professionalism, enthusiasm, and initiative.
  • Ability to work in a dynamic fast-paced, matrix environment is required.
  • Must be self-motivated and have the ability to work independently and handle multiple priorities and deadlines simultaneously with minimal guidance.
  • Ability to forge strong interpersonal relationships within the department, with other departments, and with external audiences.
  • Demonstrated ability to work in multi-disciplinary team environments.
  • Attention to detail is critical to the success of this position, with skills in customer orientation and the ability to deal with ambiguity.
  • Strong written and verbal communication skills coupled with proven and demonstrated leadership skills required.
  • Experience in a clinical field or practice management is required, as well as knowledge of coding guidelines.

Licensure, Certifications, and Clearances:

  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct

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