Highmark Health Director, Risk REvenue Program Cycle (Medicare) in Pittsburgh, Pennsylvania



This job provides overall direction, sets goals and leads the overall revenue program management strategy around revenue cycle business and operations. Functions as the business owner of risk analytics, provider engagement, risk adjustment data submissions (RAPS, EDPS, , Medicaid state- based encounter submissions), identifies and applies best practices and processes to ensure efficacy and accuracy of risk adjustment programs. Identifies and recommends both strategic and tactical improvements to these processes, and ensures compliance to all applicable laws, guidance, and regulations. Develops and sustains a long-term optimal structure and processes around emerging encounter data submission requirements; analyzing, monitoring, and planning key risk adjustment milestones and identifying improvement opportunities. The incumbent oversees the project management and business analysis functions for the Revenue Program Management division. Responsible for thought-leadership and project management expertise to facilitate the development of the department’s strategic plan, and to deliver key strategic initiatives and critical Program(s)/Project(s) within the constraints of scope, quality, time and budget. Directs the requirement development, testing and refinement of the underlying systems, defines strategic and tactical approaches to improve business systems to support the underlying workflow of these systems, and is a facilitator of the divisional planning process. Includes the oversight of staff that serve on Program(s)/Project(s) to deliver solutions for risk adjustment programs. Collaborates with stakeholders on project planning, risk mitigation, contingency planning and execution to ensure delivery of expected outcomes. Functions as the primary advisor of strategic direction on risk adjustment and collaborates and communicates with both clinical and operational executive management and external vendor partners.


  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

  • Support VP Revenue Program Management in identifying, promoting and executing process improvement strategies and programs to ensure maximum efficiencies, accuracy and completeness of encounter data submissions.

  • Facilitate the development of the department’s strategic plan by bringing together all areas of the department, along with external stakeholders, to set strategic direction. Provide project management and business analysis expertise to deliver key strategic initiatives and critical Programs/Projects.

  • Establish and maintain best practice techniques for project management and business analysis functions within the Revenue Program Management department.

  • Develop and oversee implementation of risk adjustment programs and processes for the collection, submission, and reconciliation of government required data in full compliance with all applicable laws, guidance, and regulations. Ensure member and product risk revenue profiles levels are accurate and risk revenue targets are achieved to ensure the company’s government revenue retention and growth.

  • Lead the Organization to continuously improve its revenue program performance through accuracy, timeliness and completeness of data submissions and leveraging industry leading best practices. Build and lead cross-functional teams to develop and sustain processes for analyzing and responding to ever changing CMS data submission requirements.

  • Maintain expert knowledge of principles and methods or planning, directing and maintaining compliance with risk adjustment standards. Effectively mitigate risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties.Highly collaborative and influential across the enterprise, requiring cross-functional, matrixed relationships. This includes overseeing the integration and alignment or risk adjustment, STARS/HEDIS and care management strategies, tactics and operational processes, and demonstrating ability to partner, inspire and motivate across organization structure.

  • Apply knowledge of Medicare Advantage and Medicaid to partner with other revenue program management directors in identifying opportunities to improve overall program performance.

  • Other duties as assigned.



  • Bachelor's Degree in Business Administration/Management, Finance, Health Administration or Related Field


  • None


  • Master's Degree in Business Administration/Management, Finance, Health Administration or Related Field



  • 7 - 10 years in the Health Insurance Industry

To Include

  • 7 - 10 years in Project/Program Managementin large scale, cross divisional and multi-year projects

  • 5 - 7 years in Management

  • 3 - 5 years in Managed Care


  • 7 - 10 years leading Medicare Advantage or Medicaid Risk Adjustment Programs



  • None


  • None


  • Proven leadership experience in functional and matrix aligned organizations

  • Strong communication and interpersonal skills

  • Strong management and motivational skills to coach, teach, and mentorthe team on core behaviors

  • Excellent conflict and resolution skills to successfully navigate difficult personalities and situations

  • Strong understanding of multiple software development life cycle methodologies

  • Strong understanding of Portfolio Management methodology

  • Outstanding organizational and written communication skills

  • Excellent interpersonal and oral communication skills

  • Strong leadership skills, and ability to work well at all levels within the organization

  • Strong commitment to continuous process improvement and effective change execution

  • Strong analytic problem solving skills and business acumen

  • Ability to build strong culture of collaboration and teamwork

Language (Other than English)


Travel Required

0% - 25%


Position Type


Teaches / trains others regularly

Does Not Apply

Travel regularly from the office to various work sites or from site-to-site


Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required


Lifting: up to 10 pounds


Lifting: 10 to 25 pounds


Lifting: 25 to 50 pounds


Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity