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Risk Adjustment Consultant (Provider Engagement)

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POST DATE 8/27/2016
END DATE 11/23/2016

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Under the supervision of the Manager of Risk Adjustment Strategy and Operations, this individual will support the operations and analysis of all risk adjustment programs and serve as the primary point of contact to a select portion of our provider network. This includes strategically important business partners, such as integrated delivery networks, large facilities and/or physician organizations. This individual will also work closely with internal departments and external vendors to ensure that risk adjustment programs are implemented and operated at the highest levels of performance. The Risk Adjustment Provider Engagement Consultant will also work closely with our Network Contracting, Clinical and Care Management departments to deliver timely reporting and performance management advisory services to our provider network. This individual regularly demonstrates self-direction and motivation toward completion of on-going department initiatives.

Provider Engagement, Data Analysis and Risk Score Reporting

* Develop and maintain strong and effective working relationships with key business and medical leaders at provider organizations within our network
* Manage provider outreach and ongoing communications/reporting for all risk adjustment programs and initiatives. Serve as the risk adjustment subject matter expert to address provider concerns and assist them in understanding the complexities of risk adjustment programs and the resulting data
* Coordinate and facilitate regularly scheduled and ad hoc provider meetings to provide operational updates, discuss strategic initiatives and improvement opportunities
* Build and refine medical group-specific profiles including but not limited to governance, financials, risk scores, culture and technology
* Support the evaluation of medical group opportunities and challenges specific to risk adjustment performance, identify and/or modify training needs and/or programmatic interventions to improve performance and refine the engagement plans.
* Analyze, interpret and synthesize medical group specific results and risk score trend information; deliver the results of standard (and ad hoc) analyses to improve awareness and understanding of risk score results and the quality, accuracy and identification of member health conditions
* Work collaboratively with risk adjustment provider educator and the quality assurance team to focus the provider training and education specifically related to coding accuracy, documentation and risk adjustment to high impact providers
* Perform high level financial analysis on risk adjustment programs to evaluate and report financial impact to provider organizations

Collaboration with Internal Stakeholders and External Vendors

* Develop effective and positive working relationships with internal partners (Network Contracting, Clinical Services, Sales and Marketing, Actuarial, etc.) to collaborate on provider engagement and performance improvement initiatives
* Collaborate and coordinate with internal partners in order to conduct comprehensive analysis and deliver professional presentations to our provider network at shared meetings
* Manage multi-faceted vendor initiatives to ensure smooth implementation and operations
* Support the Risk Adjustment Operations department in efforts to assess additional diagnosis program opportunities that can be procured or potentially developed internally


* Attend provider engagement meetings, document provider concerns and key decisions, manage follow up actions as necessary
* Stay informed about CMS and industry trends and best practices; utilize this knowledge to recommend modifications to THP's risk adjustment programs and provider engagement practices
* Support the development and refinement of key deliverables to our provider community, including presentations, reference material and communications

EDUCATION: Bachelor's degree required, preferably in related field. Graduate degree preferred.

EXPERIENCE: Three to five years of experience in a progressively responsible role with leadership experience in a complex operational setting or consulting role. Previous experience working in strategy implementation, analytical and process improvement in the health care / health insurance sector either for a health plan, provider group or management consultancy. Understanding of US Health Policy and experience working with CMS, health insurers and medical providers highly desired.


* Highly energetic, organized, detail-oriented, resourceful and self-motivated
* Highly proficient in Microsoft Excel, PowerPoint and Word; additional database systems a plus
* Excellent interpersonal and communication skills
* Ability to work collaboratively with both internal and external resources
* Ability to develop professional and effective relationships as a strategic advisor to our provider network
* Ability to take responsibility, prioritize tasks and follow through to completion
* Ability to organize, manage and analyze large sets of dat


* Must be able to excel in a fast paced business environment and handle multiple priorities. Must be highly effective in both written and oral communication
* Must be able to exercise appropriate judgment when making decisions
* Must be able to work in excess of 40 hours per work as the job may require, including evenings and weekends

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.