Assoc VP Risk Adj Programs (4776BR) Long Beach, California


Job Summary

The Assoc Vice President of Risk Adjustment Programs, an executive level strategic  position with direct revenue responsibility based in Molina’s corporate office in Long Beach, is the key executive at Molina responsible for designing and executing risk adjustment programs for Molina’s Medicare Advantage (SNP), Medicare-Medicaid (MMP) and Marketplace lines of business across all Molina health plans.
Molina’s risk adjustment function is heavily matrixed to health plans and to other Molina corporate departments that include quality, claims, IT and healthcare services.  The AVP of Risk Adjustment Programs is responsible for designing and executing Molina’s risk adjustment objectives through a coordinated team approach that involves the risk adjustment team, health plans, and the matrixed corporate departments.
This individual will determine the strategic direction of Molina's companywide risk adjustment program, while also insuring the achievement of strategic goals through the direction of both corporate and health plan activities.   This individual will need to direct corporate staff while also engaging and negotiating with health plan CMOs and Plan Presidents, as well as Corporate Vice Presidents and Senior Vice Presidents. The AVP of Risk Adjustment Programs will need to be the Company’s thought leader regarding risk adjustment, and must be able to persuade and lead executive level members of the management team to take the appropriate actions to insure risk adjustment of the highest quality. 
The position is responsible for the following mission critical functions at Molina Healthcare:
• Overall strategic direction of the risk adjustment program, including where to allocate risk adjustment investment and the degree and manner in which other corporate departments and health plans are to support the Company’s risk adjustment efforts.
• Prospective programs to improve risk adjustment score quality at both corporate and the health plans;
• Retrospective programs  to improve risk adjustment score quality at both corporate and the health plans;
• Management of all data collection, submission and integrity procedures;
• Implementation of internal RADV monitoring programs and support of internal and external RADV audits. 
• Medical coding of health risk assessments through prospective and retrospective programs

Essential Functions

• Sets strategic direction for Molina’s Risk Adjustment Programs
• Identifies and prioritizes risk adjustment opportunities and assigns resources as appropriate.
• Engages with senior health plan leadership to insure adequate focus on risk adjustment activities. 
• Analyzes, interprets and communicates RADV requirements; develops internal controls, and monitors compliance.
• Insures robust, on-time, and efficient data collection, validation, and submission for Medicare, MMP and Marketplace lines of business.
• Selects and manages vendors for in home assessments, medical chart retrieval, and medical coding.
• Oversees development of training content for the health evaluation assessment (HEP) program.
• Designs and Manages PCP and vendor payment.
• Development of member and provider target lists for retrospective and prospective programs.
• Makes decisions on selection of internally developed or purchased IT applications to support data collection, validation, submission, and analytics.
• Directs the coding of collected medical records according to national coding guidelines and CMS regulations
• Develops expense budget for all functions and ensures achievement of financial performance


• Experience leading risk adjustment activities in a large, multi-state Medicare HMO
• Ability to interact effectively with C-Level employees across the organization
• Knowledge of regulations related to Medicare Advantage, MMP, and Marketplace risk adjustment
• Knowledge of claim coding and payment methodology utilized in Medicare and Medicaid lines of business
• Knowledge of payment methodologies utilized to align provider incentives for complete accurate data submissions
• Knowledge of RAPS and 837I (5010) formats and file protocols
• Strong leadership capabilities, and ability to initiate and maintain cross-team relationships
• Excellent analytical and problem-solving skills
• Ability to effectively direct preparation of various financial analysis and data mining activities
• Ability to effectively interface with staff, clinicians and management
• Excellent teaming/interpersonal and verbal and written communication skills
• Ability to abide by Molina’s policies
• Ability to maintain attendance to support required quality and quantity of work

Required Education: 
Bachelor's Degree and/or a professional certification requiring formal education beyond a two-year college or equivalent experience
Required Experience:  
• 3 years Medicare risk adjustment leadership in a multi-state, D-SNP health plan environment.
• 7 – 10 years’ finance or quality management experience in a Medicare managed care setting. Demonstrated expertise in HCC activities, clinical informatics, and CMS risk adjustment regulations.
• Experience in analytics and data analysis.
• Leadership or project management experience in achieving results through others in complex matrix organization.
• Experience with the requirements of SOX and Risk Adjustment Data Validation.

Required Licensure/Certification:
Preferred Education:
Preferred Experience:
• Management of risk adjustment claim coding department.
• Management of healthcare data analytics
• Leadership or project management experience in achieving results through others in complex matrix organization.

To all current Molina employees if you are interested in applying for this position please apply through the intranet job listing. Also, fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online.

Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

To apply, please click here