Senior Manager Health Care Quality

Job DescriptionThis role will be supporting NY/NJ Medicare Chief Medicare Officer leading Stars and Risk Adjustment while serving as a liaison to various integrated lines of business, Corporate Revenue Integrity, and market health risk -educator to provide in-depth knowledge and expertise to support the education of providers to capture member risk accurately and positively impacting Stars quality care performance.Responsibilities Include:- Participating and supporting metric integration and execution for optimal results related to Risk Adjustment and Stars quality performance. - Developing and implementing market business plans to motivate providers to engage in improving Risk - Providing analytical interpretation of Risk Adjustment and Stars quality of care reporting to and with provider groups including, Executive Summaries, suspect HCCs, and HCC revalidation.- Participating and contributing to internal and external provider-facing meetings related to Risk Adjustment and Stars quality care improvement activities which summarize provider group performance and market performance as requested by or required by NY/NJ leadership.- Analyzing and evaluating provider group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies related to Risk Adjustment and Stars performance.- Supporting NY/NJ market specific chart retrieval and review of PCP, Hospital, and Specialist records- Responsible for educating providers on how to properly document medical services and interventions received during member encounters, including proper coding and claim submission for services rendered impacting risk adjustment and Stars quality care performance.- Communicating compelling and concise results to empower client groups in decision making process regarding project opportunities impacting risk adjustment and Stars quality care performance.- Gathering, analyzing, and synthesizing business intelligence to drive achievement of strategic business objectives impacting risk adjustment and Stars quality care performance.- Identifying and recommending opportunities for process improvements and shares best practices in Risk Adjustment and Stars with provider groups across all assigned provider groups in NY and/or NJ.- Position will eventually require occasional regional travel to Aetna's provider offices, clinics, and facilities.Pay RangeThe typical pay range for this role is:Minimum: 75,400Maximum: 158,300Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications 5+ years' experience with one or more of the following methodologies: management consulting, project consulting, business process consulting, financial strategic analysis, strategic business planning, and/or risk coding management consulting. Knowledge of regulatory/accreditor guidelines and NCQA guidelines Knowledge of risk adjustments or Stars quality measuresCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification required. Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing. Experience with ICD-10 codes required. Experience with Medicare and/or Commercial risk adjustment process required. Experience/understanding of electronic medical records/electronic health records in the office setting required. Demonstrated experience successfully implementing change in complex organizations. Operational experience in a relevant disciplineEducationBachelor's degree or equivalent recent and related work experience.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2024-10-19