Cigna

Risk Adjustment and Quality Senior Director- Government Segment- Work From Home

Posted on: 24 Jan 2021

Nashville, TN

Job Description

* Remote, Work from Home, United States

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

POSITION SUMMARY:

The Senior Director, Risk Adjustment and Quality is responsible for the strategy, execution and performance of Medicare risk adjustment programs, performance analysis, infrastructure and systems to meet business objectives and CMS regulations. This leader is responsible for analysis and reporting of Medicare revenue for all senior products and coordinating enterprise risk adjustment initiatives. Reporting into this position are Directors and Sr Managers that oversee physician education, data submission, quality assurance and compliance, program development and management. Leads a growing organization of over 120 employees.

RESPONSIBILITIES:

- Develop and oversee programs to ensure complete and accurate diagnosis codes are identified and submitted to CMS for all members for risk adjusted payment. Ensures that data are integrated with and utilized to improve the management of members care.

- Monitor and analyze the effectiveness of programs, processes, infrastructure, and reporting, and make changes to improve results and effectiveness.

- Ensure timely, accurate and complete submission of risk adjustment data to CMS and reconciliation of plan payments.

- Oversee internal and vendor processes, controls and reporting to ensure effective processes are in place throughout the organization. Ensure timely correction and resubmission of data errors from CMS.

- Develop, execute and continually refine a quality assurance program to monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of internal staff and contracted vendors.

- Develop and implement strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.

- Develop and implement programs for provider training and education on HCC risk adjustment, proper medical record documentation and diagnosis coding accuracy.

- Develop and enhance infrastructure and reporting to support QA programs

- In collaboration with markets, develop and oversee the execution of strategies, programs and plans to engage contracted medical group physicians in proper assessment, coding and documentation of all members. Develop and implement remediation strategies as needed with individual providers, provider groups and the network as a whole.

- Collaborate with key internal stakeholders (Clinical Services, Network Contracting, Actuarial, Legal, and Compliance) to develop, implement, and continually refine prospective and retrospective diagnosis coding programs and provider support.

- Develop and oversee reporting of specific results to improve quality, accuracy and identification of member health conditions

- Develop and utilize analytics to identify opportunities and risks and develop interventions to address

- Utilize analysis to identify trends and opportunities for improvement, new strategies and further program development

- Collaborate with Clinical Services leadership on the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.

- Develop, lead and refine processes to project, plan, analyze and report on revenue trends for all Senior Products

- Stay informed about CMS and industry trends and best practices and utilize this knowledge to refine and advance risk adjustment programs.

REQUIRED SKILLS:

- Consistent high-level leadership and performance, with demonstrated achievement.

- 10 or more years Risk Adjustment/Compliance related healthcare/CMS business experience.

- 5 or more years management experience in healthcare overseeing quality, risk adjustment, or compliance

- Bachelors degree required, Masters degree healthcare or related field preferred

- Extensive knowledge of regulatory compliance environment, including, CMS, Patient Protection and Medicare Advantage or Affordable Care Act.

- Comprehensive knowledge of Cigna HealthCare lines-of-business.

- Ability to analyze and apply complex statutory and regulatory information to CHC products and operations, and to interpret and explain contractual provisions.

- Process improvement knowledge and experience.

- Successful project management experience in highly matrixed environment, with proven results.

- Strong facilitation, influencing, negotiating and relationship building skills to work across matrix partner areas.

- Excellent written and oral communication skills.

- Strong planning/organizing/prioritizing skills with ability to meet changing priorities and critical deadlines.

- Takes personal accountability for team and organizational results.

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, youll enjoy meaningful career experiences that enrich peoples lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search TeamCigna on Instagram.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

Cigna

Bloomfield, CT

Cigna Corporation, a health service organization, provides insurance and related products and services in the United States and internationally. It operates through Integrated Medical, Health Services, International Markets, and Group Disability and Other segments. The Integrated Medical segment offers medical, pharmacy, dental, behavioral health and vision, health advocacy programs, and other products and services to insured and self-insured clients; Medicare Advantage, Medicare Supplement, and Medicare Part D plans to Medicare-eligible beneficiaries, as well as Medicaid plans; and health insurance coverage to individual customers on and off the public exchanges.

The Health Services segment provides clinical solutions, specialized pharmacy care, home delivery pharmacy, retail network pharmacy administration, benefit design consultation, drug utilization review, drug formulary management drug claim adjudication, digital consumer health and drug information, provider, and medical benefit management services. The International Markets segment offers supplemental health, life and accident insurance products, and health care coverage, as well as health care benefits to mobile employees of multinational organizations.

This segment offers health coverage, hospitalization, dental, critical illness, personal accident, term life, and variable universal life products. The Group Disability and Other segment provides group long-term and short-term disability, group life, accident, and voluntary and specialty insurance products and related services; and permanent insurance contracts to corporations to provide coverage on the lives of certain employees for the purpose of financing employer-paid future benefit obligations. The company distributes its products and services through insurance brokers and insurance consultants; and directly to employers, unions and other groups, or individuals. Cigna Corporation was founded in 1792 and is headquartered in Bloomfield, Connecticut.