ED, Risk Adjustment Submissions & Data Integrity

The Executive Director for Risk Adjustment Submissions & Data Integrity is the Kaiser Foundation Health Plan leader responsible for supporting Kaiser Permanente’s commitment to submitting complete and accurate risk adjustment data to the Centers for Medicare and Medicaid Services (CMS). This is done in partnership with Permanente Medical Groups and various national Health Plan partners such as Revenue Management, Information Technology, and the National Claims Administration. The scope is large, with annual revenue for KPs members who are reimbursed through risk adjusted payment models of approximately $37 billion or 37% of KPs revenue. The person in this role provides operational and management expertise and guidance for risk adjustment data submissions and related data integrity by identifying and following through on opportunities to support completeness and accuracy of the risk adjustment data submitted to CMS and HHS. This role is also responsible for assessing the impact of proposed and finalized regulatory changes and leading organizational response to comply with risk adjustment data submission requirements. This also includes partnering with Legal, Compliance, and Government Relations departments to understand and assess organizational impacts on data submissions, mitigate risks, and communicate with regulatory bodies as necessary. A strong business background and understanding of operations for both the Health Plan (payor) and Delivery System (provider) is necessary for the Executive Director of Risk Adjustment Submissions & Data Integrity role. The incumbent needs an understanding of data flows, system integrations, finance or accounting, and government regulations. The Executive Director of Risk Adjustment Submissions & Data Integrity must have a proven track record of working with complex systems and data, medical group partners, national and functional leaders, and be passionate about designing and operating systems and processes to effectively and efficiently meet compliance obligations. They must be confident to present their findings to all levels of the organization, including peers, senior management, internal customers and regulators. The Executive Director of Risk Adjustment Submissions & Data Integrity will be required to drive improvement efforts, design and develop reporting based on the operating needs of the organization, and oversee the ongoing development of robust submissions and reporting platforms that contain critical information to support compliance requirements. The incumbent will be one who maintains updated knowledge, possesses sensitivity toward the business environment, and feels comfortable in making rational judgments. The Executive Director of Risk Adjustment Submissions & Data Integrity must be knowledgeable about complex organizational data flows within Kaiser Permanente as an integrated care provider and understand how those impact the ultimate submissions to CMS. This includes partnering with upstream data owners to identify and remediate data gaps as needed and maintain submission systems and related operational reporting to support efficient and effective submissions.

• In conjunction with the VP, Risk Adjustment Data & Analytics, sets the strategic direction and organization of KPs Risk Adjustment submissions and data integrity function to facilitate achievement of the Finance business goals and objectives.  


• Oversees resources managing technical systems and providing operational dashboards to business leaders and stakeholders to support business decision making regarding the completeness and accuracy of data submitted to CMS and HHS.  


• Analyzes proposed regulatory changes and makes recommendations to CMS and HHS on policies and practices relating to Risk Adjustment.  


• Collaborates with other members of the Risk Adjustment leadership team to prioritize management reporting and information, focusing on those areas that have the greatest impact on decisions to support complete, accurate and truthful regulatory submissions.  


• Works with market Risk Adjustment, Medical Group and Revenue Management partners to assess internal practices and make recommendations to develop/adjust strategy to meet changing business and regulatory conditions.  


• Ensures that performance targets are set and clearly communicated.  


• Assesses the Risk Adjustment teams performance against goals and objectives.  


• Serves as liaison with key stakeholders including NMF Accounting, NMF Strategic Analysis, Financial Planning, KP Medicare Program, National Compliance Office, Legal, Actuarial Services, Revenue Management, National Claims Administration, Information Technology and sister departments within the Risk Adjustment Data & Analytics organization. 


• Builds and maintains collaborative partnerships with the Medical Groups, functional leads involved in risk adjustment and other market and program-level leaders to enhance the success of Risk Adjustment initiatives nationally and regionally and support the KP Value Compass (affordability, quality, service, best place to work).  


• Travel to operating units to engage stakeholders is expected.

This position has a target base salary of $229,500 to $286,875 and is eligible for incentive compensation, comprehensive health, wellness, time off, savings, and retirement benefits, as well as relocation support, as applicable.