• Job Description

  Req#: 23010900

  Director of Medicare Part C Risk Adjustment Compliance

  • Responsible for overseeing Part C Medicare Advantage Risk Adjustment Compliance Department
  • Provide leadership and direction to ensure alignment between Compliance and the business
  • Develop, implement, and manage programs related to Medicare Risk Adjustment including, but not limited to, HCC/diagnosis code accuracy, diagnosis code submission, mock audit, and Risk Adjustment Data Validation (RADV) Audit
  • Monitor and refine existing Risk Adjustment programs
  • Minimize risk by staying current on regulations, assess and analyze their significance and impact, and recommend policies to ensure compliance
  • Stay abreast of industry changes and/or trends including, but not limited to, Federal Risk Adjustment cases, and provide awareness to Compliance, Legal, and business owners on potential risks, issues, and policy enhancements
  • Develop and direct internal Risk Adjustment Compliance initiatives, audit and monitoring activities (e.g., Risk Assessment, Audit Work Plan development and execution, mock audits, audit readiness activities, etc.)
  • Collaborate with all areas of compliance, the special investigations unit, Legal, and business owners to identify potential risks and to drive process improvements
  • Collaborate with business owners to ensure alignment between Compliance and the business
  • Develop and communicate/present compliance reports to leadership, business owners and established committees
  • Responsible for managing Risk Adjustment Compliance team
  • Oversee Part C audit and monitoring activities related to coding and risk adjustment for the Cigna Compliance Department, with particular emphasis on Coding, Risk Adjustment and Coding Decisions.
  • Responsible for reviewing policies and procedures for designated business areas to ensure regulatory and risk adjustment compliance.

  Qualifications:

  • Master’s degree or equivalent
  • 10+ years of experience with Medicare Risk Adjustment is required
  • Experience leading a team of professionals required
  • Expert knowledge of Medicare Advantage Risk Adjustment, compliance and regulations required
  • Strong knowledge of Risk Adjustment and Hierarchical Condition Category (HCC) coding
    payment model (i.e., v22 and v24) required
  • 10+ years of experience working with Medicare Advantage, Medicare-Medicaid Plan (Dual-Eligible) and/or Medicaid a must
  • 10+ years management/leadership experience
  • 5+ years of experience with auditing
  • Coding certification preferred but not required
  • Strong knowledge of claims, encounters, risk adjustment and CMS submission process required.
  • Experience with Risk Adjustment Data Validation Audits preferred but not required
  • Strong leadership and interpersonal skills with the ability to work with a diverse group of people across the organization and externally
  • Remote role

  
  

  If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

  For this position, we anticipate offering an annual salary of 149,600 - 249,300 USD / yearly, depending on relevant factors, including experience and geographic location.

  This role is also anticipated to be eligible to participate in an annual bonus and long term incentive plan.

  We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

  About The Cigna Group

  Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.

  Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

  If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

  The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

• About the company

  Cigna is an American worldwide health services organization based in Bloomfield, Connecticut.

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