Senior Director Coding and Billing Operations

Job Summary

GENERAL SUMMARY

We are looking for an individual with deep coding and billing experience with risk adjusted models in value-based care who is looking for an exciting challenge to join WellBe’s Operations team to oversee coding and billing services for the organization.

Job Description

POSITION RESPONSIBILTIES

• The Vice President of Coding and Billing Operations is responsible for overseeing all billing and coding services for the company, including management of third-party vendors, quality assurance and coding education.
• Builds strong partnerships with WellBe’s cross-functional teams including Clinical Operations, Markets Operations, STARS, Compliance, and leadership to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and accuracy of coding
• Develops digitally enabled workflows and key performance reporting to ensure process adherence and consistent value delivery
• Ensures that WellBe’s Risk Adjustment programs comply with all applicable guidelines, regulations and laws established by the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), and any other regulations or statutes established at the local, state and federal levels
• Ensures appropriate codes for each Quality Metric (STARS and HEDIS) is accurate and complies with all applicable guidelines
• Oversees clinical documentation for accuracy and completeness
• Manages the claim submission process, completes analysis and immediate action on rejections, and validates submitted codes accepted by the health plan for reimbursement
• Creates a culture focused on Compliance and Core Behaviors
• Prepares and oversees audits inquires by government agencies (e.g., CMS, HHS), internal Compliance and other validation audits to ensure efficacy of documentation, coding and quality for WellBe members including, the collection and validation of historical member clinical data to fulfill CMS audit requests; including retrieval of medical records, validation of member clinical conditions and confirmation of reimbursement values received from CMS
• Develops and implements provider education strategies and tools, monitoring provider performance, developing corrective action plans, direct provider interventions, and assisting physicians and markets that perform below quality benchmark
• Serves as escalation to providers who require intervention
• Owns program outcomes to ensure complete / accurate assessment and documentation of member profile
• Execution of HEDIS abstraction
• Develops improvements for HCC and Quality metric capture in the EHR
• Track billing and coding production and outcomes while owning results for accuracy and efficiency
• Develop and provide necessary educational programs and materials for organization and clinicians to include topics of Coding, Clinical Documentation Improvement and ICD10
• Oversee analysis of both market level and individual clinician performance and provide dashboard of overall performance as well as subsets by disease categories to identify areas for more intensive and focused training
• Present HCC Coding Materials to physicians effectively and provide oversight and leadership of 1:1 presentations to poor performing clinicians who code outside of clinical support as well as leave HCC gaps
• Oversee employed clinicians' chart audit, review, and accuracy process
• Oversee vendors to assure compliance and outcomes

Other duties as assigned

Job Requirements

QUALIFICATIONS

Educational/Experience Requirements:

• Bachelor's Degree in Business Administration/Management, or 10 years of relevant experience in lieu of Bachelor's Degree. Master’s Degree in Health Administration preferred
• 12 years in the Value-Based Healthcare Industry
• 7 years management experience in Medical Coding and Clinical Documentation
• 7 years in Risk Revenue and HCC Coding
• 5-7 years in Operational Excellence
• 3 - 5 years of claims experience as a biller or supervisory capacity
• AAPC, Certified Professional Coder (CPC)
• AAPC, Certified Risk Adjustment Coder (CRC)
• Current knowledge on all CMS billing/coding regulations
• Licensure/Certification (CCS-P, CPC, RHIA or RHIT)

Required Skills and Abilities:

• Expertise operating in a value-based care environment, with knowledge of coding guidelines, HCC payment models, and best practices in clinical documentation, auditing, coding and billing (J-codes, Z-codes and AWP)
• Vendor management for a disciplined line of sight, control and optimize revenue collection
• Thorough knowledge of anatomy, physiology, pharmacology and medical terminology
• Comprehensive knowledge of coding and billing practices and official guidelines, HCPCS, ICD-9/ICD-10 and CPT, HCC (Hierarchical Condition Categories), Medicare Risk Adjustment (MRA), Healthcare Effectiveness Data and Information Set (HEDIS), as well as requirements with emphasis on Center for Medicare/Medicaid (CMS), and Office of Inspector General (OIG)
• Auditing skills for quality and compliance
• Strong analytical background, as this individual will be counted on to create suspected HCC diagnoses lists and identify clinical opportunities based on trends in coding data. The diagnoses/problem lists are based on clinician medical records and should not be supplemented by additional areas. 
• Current on all coding / billing regulations and best practices and be able to relay this information to the clinical team
• Proficiency in Microsoft applications, including Outlook, Word, Excel and Power Point
• Self-starter, proactive, who works quickly and accurately and will prioritize and meet deadlines effectively
• Professional demeanor and demonstrated leadership ability; composed and effective under pressure and able to adapt to new and changing business conditions
• Solid leadership, analytical, project planning and coordination skills
• High energy: demonstrates an ability to function in a creative, entrepreneurial environment and think outside the box

Travel requirements: 20% local or national travel required

Work Conditions:  This position will work in a variety of settings, e.g. office. The noise level in the work environment is usually moderate.   Requires prolonged sitting.  Requires bending, stooping, twisting, kneeling, crouching, crawling and/or stretching from seated or standing positions. Requires eye-hand coordination and manual dexterity sufficient to operate medical equipment, frequently operates a keyboard, telephone, copier, calculator and other office equipment.  Manual dexterity and coordination necessary to operated office equipment, telephone, keyboard, copier and calculator.  Requires close vision, peripheral vision, and ability to adjust visual focus, hearing and smelling.  Must be able to communicate information via telephone or computer.  Requires moderate to intense concentration due to complexity.  Must be able to lift and/or move up to 25 lbs.

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.