Risk Adjustment Manager


Risk Adjustment Manager

  • Remote

Hi, we’re Oscar. We’re hiring a Risk Adjustment Manager to join our Risk Adjustment team.

Oscar is a technology-driven, consumer-focused health insurance startup founded in 2012 and headquartered in New York City. Our goal is to make health insurance simple, transparent, and human. We need your help to do so.

About the role:

Effectively manage and direct the In Home Assessment Program, Point of Care Programs, Auditing Program, and Risk Adjustment department to meet the needs of its internal customers and the requirements of our regulatory agencies. The individual will provide leadership and management skills to achieve efficiencies and contribute to creating an insurer of choice for current/prospective customers and a workplace of choice for associates. Success will be based on the individual’s professional ability to lead a team toward a common goal, effectively communicate and manage complex regulatory issues creating competitive value in the marketplace and plan activities.

You will report into the Director, Revenue Operations.

Responsibilities:

  • Responsible for State and Federal regulatory activities working to promote and ensure Risk Adjustment activities are compliant with all applicable laws, regulations, rules and policies.
  • Conduct special studies/projects and identify opportunities for operational improvements consistent with Oscar’s strategic goals.
  • Manages the In Home Assessment Program to meet business objectives, CMS regulations and quality standards for Medicare Advantage and ACA Risk Adjustment, including provider education, coding, auditing and referrals along with the daily operations of the Risk Adjustment coders and auditors
  • Manages the development of provider audit processes to meet and maintain regulatory/accreditation/operational requirements, including reporting a detailed analysis of the issue, making recommendations and following the outcome.
  • Manages the internal audit processes to ensure that the Risk Adjustment record review team and Auditors meet and maintain departmental quality standards and that data submitted as a result of these reviews is thorough and accurate.
  • Manages the development and oversight of Point of Care Programs in order to provide complete and accurate Risk Adjustment and HEDIS data on behalf of membership to regulatory agencies.
  • Accountable for creating a culture of compliance with Oscar’s core values, policies & procedures and applicable regulatory requirements and standards.
  • Develops and makes decisions regarding appropriate forecasting methods and tools for financial reporting. Design, prepare and produce reports related to the In Home Assessment Program, Point of Care Programs and Risk Adjustment Coding at the plan level and driving an overall management process to analyze the expected impact on revenue.
  • Responsible for coaching and development of a team.

Requirements:

  • Bachelor’s degree in relevant field of study or 5+ years of related work experience
  • Certified Professional Coder (CPC)
  • Subject matter expert in areas of Medicare and Commercial Risk Adjustment
  • Risk Adjustment Data Validation (RADV) experience.

Bonus points:

  • PAHM or other health related certification (required within first year of employment)

Life at Oscar:

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We’re on a mission to change health care — an experience made whole by our unique backgrounds and perspectives.

We encourage our members to care for their whole selves, and we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

Pay Transparency Policy:

Oscar ensures that you won’t be discharged or discriminated against based on whether you’ve inquired about, discussed, or disclosed your pay.



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Oscar Health Insurance

Oscar
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