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Sep 14th, 2021

Risk Adjustment - FW&A Compliance Director

Full Time

A bit about us: 

We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being. 

That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly. 

"We want to partner with people we love for a cause we believe in. Life is short. Join us."


Position Summary:  

The Risk Adjustment - FWA Compliance Director is responsible for monitoring and auditing our risk adjustment program as well as working closely with our SIU program in ensuring compliance with our Fraud Waste and Abuse plan.  This role acts as the Risk Adjustment Compliance subject matter expert and as the Compliance lead on FWA. The Compliance Director of Risk Adjustment and FWA works closely with other areas of health plan operations and programs, and ensures risk adjustment data operations are administered accurately, timely and in compliance with CMS regulations as well as our implementation of FWA.

Role responsibility:

  • Implements and oversee the Risk Adjustment and FWA Compliance monitoring and audit program
  • Overseeing the relationship with our external Compliance auditors of our Risk Adjustment program
  • Develop and execute a compliance a Risk Adjustment audit schedule, analysis of compliance monitoring reports and directing and overseeing the self monitoring activities performed by the operational departments and reported on CPE
  • Maintains knowledge of applicable current and proposed laws, regulations, and sub-regulatory guidance (e.g., CMS) applicable to Risk Adjustment and FWA specifically and general knowledge of Medicare Advantage requirements 
  • Actively researches and stays current with requirements from CMS to ensure that risk adjustment program is in compliance with government regulation 
  • Responsible for oversight and communication of the FWA program.
  • Oversee the monitoring of the FWA program
  • Works closely with our SIU team and our FWA vendor which is the primary driver of FWA programs
  • Assist in the development of the annual work plan which will outline and detail the annual FWA monitoring plan.
  • Ensures all FWA issues are investigated and assist in notification of MEDIC and other state and federal agencies of potential fraud activities
  • Manage and oversee the preparation and submission of FWA regulatory reporting requirements to CMS and other agencies.
  • Partners with the Sr. Compliance Director of vendor management to assist in the oversight of Risk Adjustment vendors as well as FWA vendors 
  • Drafts and maintains Medicare Compliance Policies as it relates to functions overseen by your department
  • Promotes a culture of Compliance by assisting the Chief Compliance Officer with training employees, tracking and investigating instances of non-compliance and FWA
  • Supports the operations team with policy interpretation and implementation of a compliant operation
  • Assist the Chief Compliance Officer in developing the appropriate dashboards and reports for the Devoted Health Board of Directors
  • Escalate issues to the Chief Compliance Officer and Senior leadership

Attributes to success:

  • Ability to work in a start-up, fast-paced environment
  • A desire to keep improving our program and initiatives
  • A passion for Medicare and the beneficiaries we serve
  • A team player who can roll up their sleeves and jump in
  • You have a bias towards action and execution, and a track record to support your ability to get things done
  • Clear head for process and technology
  • You have stamina for tackling hard problems
  • Communicate with internal and external stakeholders - progress reporting and vendor management 
  • Facilitate sharing of expertise by training other departments in support of risk adjustment and FWA program
  • Ability to motivate staff at all levels 

Qualifications:

  • 5+ years of experience in Medicare Part C&D Audit and Compliance 
  • Bachelor degree, master’s preferred
  • Knowledge of CMS program requirements and applicable Federal regulations overseeing the Medicare Advantage and Prescription Drug Program
  • Prior experience with CMS risk adjustment a must. 
  • Experience with risk adjustment data validations or equivalent compliance audits
  • Knowledge of CMS Fraud Waste and Abuse program requirements
  • Strong technical skills to support CMS uploads, audit tracking, risk assessments and ad hoc projects
  • Strong internal and external communication skills to effectively interact with senior management as well as Federal regulators
If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you! 

Devoted is an equal opportunity employer.  We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

COVID-19 Vaccination Requirement: Where permitted by applicable law, candidates must have received or be willing to receive the COVID-19 vaccine by date of hire to be considered. The Company will provide reasonable accommodations to qualified employees with disabilities or for a sincerely held religious belief, practice, or observance.