Description

Wage Range: $80,000- 95,000/ year

Job Summary

Accountable for developing continuous improvement strategies and directing implementation that delivers operational excellence, resulting in high performance in Medicare Risk Adjustment (MRA) and CMS Star programs. Develop, manage, maintain, and support activities and processes related to compliance with local, state, and federal regulatory authorities for HCC coding and audit programs. Manage provider educator team to ensure provider education programs meet established goals pertaining to MRA and quality measures. Provide support to performance improvement initiatives and audits tied to quality and clinical management programs, and member engagement functional areas. Ensure cross-functional collaboration that meets the accurate & appropriate codes submission goal and also improves quality of care delivery, member experience and outcomes.

Functions & Job Responsibilities

· Formulate, direct, implement, administer, supervise, and plan enterprise-wide performance measurement-based strategies relative to Medicare risk adjustment (MRA)

· Drive the definition, measurement, and implementation of MRA improvement activities and projects in support of corporate goals.

· Lead the provider educator team (and vendors) to manage MRA and quality measures education and metrics improvement. Develop and share provider education opportunities with internal teams/PCPs/IPAs/MSOs.

· Create compliance policies and review patient records in accordance with compliance policies and coding guidelines.

· Develop workflows to perform quality assurance (QA) auditing.

· Organize, lead, and participate in coding reviews/audits of medical records for RA reporting of all supported HCC conditions for submission to CMS.

· Responsible for planning, scheduling, and conducting coding audits; and maintaining records of provider or vendor audit results for HCC diagnosis codes.

· Document and present audit findings to the HCC Program team, providers, vendors, and other internal departments in an organized and actionable format.

· Educate and train peers and providers on a one-to-one or group basis to ensure accurate documentation and improve quality of care. The training could be in provider offices, hospitals, via webinars/conference calls/email correspondence, etc.

· Collaborate with other areas/departments of the company, external vendors, and medical groups to improve or maintain healthcare quality and risk adjustment metrics and programs.

· Work closely with quality team to develop year-round provider education campaign strategy and parameters.

· Improve core process efficiency, effectiveness, and responsiveness; measure and improve business critical operational KPIs/metrics.

· Maintain up-to-date knowledge and coding credentials, current updates to governmental requirements and plan requirements related to proper coding through continued education, research and reading resource material.

· Positively influence the behavior of others and inspire them.

· Other duties as assigned.

Key Risk Adjustment Programs & Initiatives:

· Define and formulate data-driven strategies, as well as manage operational activities in an efficient and effective manner, and in compliance with state and federal regulations and requirements.

· Manage risk adjustment coding teams/programs through the complete and accurate assignment of disease condition codes; to review and educate providers of the best coding practices.

· Develop/Manage OIG audit, mock RADV and RADV programs.

· Develop programs and training materials for coding compliance monitoring and clinical documentation improvement (CDI).

· Develop and utilize risk-based audit approach to establish scope of reviews by incorporating patterns and trending analysis.

· Mange various audit programs and oversee compliance from the coders, vendors, and providers. Prep and share feedback with the entities in a timely manner.

· Identify patterns and trends for educational opportunities.

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values

• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining and sharing exciting possibilities

• Enlist others in a common vision by appealing to shared ambitions

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve

• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships

• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence

• Celebrate the values and victories by creating a spirit of community

#LI-hybrid

Qualifications

Qualifications

Education and Experience:

· Bachelor’s degree in Healthcare, or related field required or 10 years HCC coding/auditing and diagnostic coding and education experience.

· Health Plan experience preferred.

Licenses/Certifications:

· Current Coding Certification in one or more of the following: CPC, CPC-H, CPC-P, CCS, CCS-P, CCA, CPMA.

· Valid Driver’s License and proof of auto insurance.

Experience:

· Subject matter expert for accurate and appropriate risk adjustment coding and CMS data validation.

· Minimum of five years in MRA and/or HEDIS/Star program management and leadership.

· Experience in education/training HCC risk adjustment coding and documentation

· Experience in program performance measurement, analytics, reporting and forecasting for MRA/Quality programs and measures.

· Experience in educating/training providers and office staff.

Skills:

· Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes, of MRA and Star/HEDIS.

· Expert in MRA coding and quality data abstraction concepts.

· Thorough knowledge of advanced ICD-10-CM coding rules and correct application in the context of HCC coding.

· Excellent leadership skills and the ability to influence line management decisions with data driven facts.

· Strong management, problem solving, priority setting skills.

· Strong independent decision-making skills.

· Strong organizational skills including time and project management skills.

· Computer proficiency in MS Office applications (word processing, spreadsheet/database, presentation).

· Possess strong results-oriented process improvement capabilities.

· Strong problem solving and analytical skills to be applied to a wide array of business problems and challenges.

· Solid change leadership, facilitation, oral and written communication, and presentation skills.

· Detail oriented with exceptional written and verbal communication skills.

· Ability to maintain composure and effectiveness in a rapidly changing environment with minimum direction.

· Must be a self-starter and independent thinker.

Physical & Working Environment.

Typical Physical Demands. Position requires a great amount of driving, sitting and standing. Some standing, stooping, bending or reaching is required. May require lifting up to 15 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions. Work is performed in an office environment and/or remotely. The job involves frequent

contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. 

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.