Senior Vice President, National Risk Adjustment Strategy

The SVP, Risk Adjustment Strategy will have accountability for the strategic vision, multi-year roadmap, and operational execution of Kaiser Permanente’s quality-oriented risk adjustment programs and establishing a value-based Center of Excellence for this work at the National Health Plan level. 

• Strategy and Vision: 
  
  
  
  • This role will require a comprehensive understanding of the regulatory and compliance environment, the intersection of risk adjustment with clinical and quality programs, and an understanding of the best-in-class and innovative technology and tools available in the market upon which to build this foundation, including driving the appropriate business cases to achieve that objective. 
  
  
  • It will further require an understanding of the provider value-based landscape, clinical workflows and tools, and the data analytics necessary to work collaboratively and transparently with our physician partners. 
  
  
  • It will necessitate an understanding of how patient population prevalence and acuity influence and inform product development, growth, and retention strategies. 
  
  
  • This role will work across the Kaiser Permanente organization and with external delivery system partners in a systems-oriented approach to ensure that clinical quality, financial sustainability, and regulatory goals are achieved in the most accurate and compliant manner.
  
  
  
  


• Clinical Data Integrity and Accuracy:
  
  
  
  • This role will be accountable for the overall quality of the clinical data that we submit to our regulator and Commercial customers for risk adjustment, partnering with our physicians, clinicians, and coding professionals, along with data analytics, revenue cycle, and compliance support teams.
  
  
  • This will consist of training and education, coding integrity and continuous quality improvement feedback, concurrent and retrospective review processes, and comprehensive data analytics of submission and feedback files from regulators and customers.
  
  
  • This role will also ensure that source systems and data warehouses, as applicable, are updated to reflect the most accurate information about a patient record.
  
  
  
  


• Risk Stratification and Prospective Algorithms to Determine Patient Risk:
  
  
  
  • Evaluate and implement analytical and predictive tools for improving identification of care gaps and promoting comprehensive care.
  
  
  • This role will work collaboratively across the National Health Plan, Care Delivery, and the Permanente Medical Groups to align on both strategy and execution of that data to inform clinical, quality, and operational performance levers.
  
  
  
  


• Clinical Program Development and Quality Strategy:
  
  
  
  • This role will leverage risk adjustment data and associated insights to inform clinical programs and quality strategies for use in complex care management, high-risk programs, and other 5-Star program elements.
  
  
  • Data from this program will also inform care delivery strategies including community-based primary or supportive care, or other operating model considerations designed to improve access to care.
  
  
  
  


• Data Submission and Reconciliation:
  
  
  
  • This role will be accountable for the accuracy, completeness, timeliness, and optimization of all data submissions to regulators, customers, and other key stakeholders, and will perform root cause and trend analysis to inform upstream operational processes to improve the delivery of such data.
  
  
  
  


• Performance Management, Reporting, and Benchmarking:
  
  
  
  • This role will inform and develop a comprehensive and robust data analytics strategy and performance management reporting suite to ensure full transparency over risk adjustment reporting for all lines of business, inclusive of benchmarking against best practices and publicly available data. 
  
  
  
  


• Risk Adjustment Factor Forecasting: 
  
  
  
  • In partnership with national finance, actuarial, and other leaders, support the accurate development of Enterprise, product level risk adjustment forecasting for financial, clinical, and other product development and actuarial modeling such as the Medicare Advantage annual bid process and the ACA rate filings, among others.
  
  
  
  


• Product Development and Growth Strategy:
  
  
  
  • This role will partner with actuarial and product teams to leverage condition prevalence data and forecasts to improve the suite of products that Kaiser Permanente can deliver to current and prospective members and customers based on the current and expected prevalence and acuity of conditions and healthcare needs of the population.
  
  
  • This may include core benefits, supplemental benefits, clinical programs, and pharmacy programs or formulary modifications, among others.
  
  
  
  


• Provider Strategy and Value Based Program Development:
  
  
  
  • This role will partner with Kaiser Permanente regional leads, national contracting, and other clinical and operational stakeholders, to develop population health and value-based reimbursement strategies that align with accurate and comprehensive coding and documentation, quality, and risk adjusted total cost of care management. It will also include the scoping, sourcing, and implementation of integrated tools with the external delivery system to support value-based care delivery for our network partners.
  
  
  
  


• Regulatory Compliance:
  
  
  
  • This role is accountable for understanding all regulatory parameters around accurate and complete clinical coding and documentation in alignment with current regulations for all products, as well as understanding the strategic direction of the regulator and oversight bodies to proactively anticipate future changes.  This role will partner with Ethics & Compliance and/or Legal, as appropriate.
  
  
  
  


• Policy and Advocacy Strategy:
  
  
  
  • This role will partner with government relations, trade associations, regulators, and other internal and external stakeholders to advocate for risk adjustment strategies that promote high quality, clinically appropriate care as well as financial sustainability and actuarially supported models for accurate reimbursement reflective of the costs associated with the populations we serve.
  
  
  
  


• Vendor Management:
  
  
  
  • This role will selectively secure and manage vendors that meet stringent Kaiser Permanente clinical and compliance requirements to support our risk adjustment program.
  
  
  • This will entail creating performance management and oversight protocols to ensure the highest standards of quality and compliance.
  
  
  
  


• Internal Stakeholder Management:
  
  
  
  • Develop an aligned risk adjustment system across all internal stakeholders, inclusive of our Permanente Medical Group partners, to ensure open communication, transparency of data, and the appropriate intersection and alignment of clinical, care delivery, quality, operational, product, financial/actuarial, and compliance stakeholders, among others.
  
  
  
  


• Team Leadership and Development:
  
  
  
  • Ensuring the right skills, capabilities, and development opportunities exist for the risk adjustment team.
  
  
  • Recruiting and retaining talent to the organization to support objectives and promote the highest quality risk adjustment team.
  
  
  • This role will also need to integrate and oversee consultants or other team members who may provide technical, strategic, or other support to the risk adjustment team.