AVP Stars and Risk Adjustment National Medical Director

Profile

Job Information

Humana

AVP, Stars and Risk Adjustment National Medical Director

in

Pittsburgh

Pennsylvania

Description

The Healthcare Quality Reporting & Improvement (HQRI) organization is seeking a talented Physician executive that can contribute to Humana's national planning and operations for Risk Adjustment, Stars, and Interoperability. Specifically, this role will carry a set of individual contributor and leadership responsibilities.

As an individual contributor, this role will: 1) inform and support HQRI's provider strategy across Stars, RA, and Interoperability, 2) serve as a coding expert to manage escalations or establish compliant policies, and 3) contribute as a clinical industry representative.

As a leader, this role leads HQRI's Provider Support team (PST) that drives national provider education strategy and operations along with provider communication operations.

HQRI is an organization with over 900 associates that leads Humana's Stars, Risk Adjustment and Interoperability strategy, operations, and performance nationally.

This role relies on medical background, business acumen, and industry-standard clinical / coding guidance to ensure physician and healthcare provider plans, education, reporting and materials are accurate and consistent across the enterprise to support regional and corporate strategic initiatives.

Responsibilities

The Associate Vice President (AVP), Stars and Risk Adjustment National Medical Director leads key strategic and operational functions. In collaboration with corporate stakeholders and regional teams, this role is responsible for supporting corporate and regional strategies for physician and healthcare provider education or operations for Risk Adjustment and Stars. In addition, the position provides supportive clinical and coding expertise across the teams in HQRI. Lastly, this leader will be instrumental in supporting interoperability efforts. This position reports the Vice President of Strategy Advancement in the Healthcare Quality Reporting and Improvement organization (HQRI) and collaborates significantly with the HQRI Senior Leadership Team across its programs.

This is a remote position with travel expectations up to 25%.

Major responsibilities include

Inform HQRI's provider strategy and increase adoption of Humana's Stars, MRA, and interoperability strategy and programs

Lead a team/organization of 10 associates across three functions: Education of Humana's Market-based associates on how to drive accurate reporting through provider education; Provider communications; policies and procedures aligned to those functions

Serve as HQRIs clinical industry representative (e.g., Conferences; national vendor or provider partners)

Serve as a coding expert, which may include working through escalations on coding disputes, policy development or refinement, and coordination and education with providers or Humana associates

Required Qualifications

MD or DO degree

A current and unrestricted license in at least one jurisdiction

Board Certified in an approved ABMS Medical Specialty

Excellent communication skills, both written and verbal

5 years of established clinical experience

Knowledge of the managed care industry including Medicare, Medicaid and / or Commercial products

Must be passionate about healthcare quality and contributing to an organization focused on maintaining accuracy of coding and documentation to capture the true health status of our members thru risk adjustment initiatives

Experience with quality assurance and/or regulatory compliance

Travel up to 25%

Preferred Qualifications:

Certification in diagnosis coding (must receive AAPC certification within one year of hire)

Ability to help develop and use data and analytics to drive sustainable results

External communications for physicians and healthcare providers

Prior experience leading teams focusing on the accuracy of medical record documentation and diagnosis coding

Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

Working knowledge of risk adjustment concepts

Internal Medicine, Family Practice, Geriatrics, OBGYN, Hospitalist clinical specialty

Detail oriented and effective listener

Experience with Stars, including HEDIS, CAHPS and HOS

Prior experience in a business function or business consulting role

Additional Information:

Vaccine Policy

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters.

Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com