Responsible for planning, leading and oversight on a national level of coding reviews and analytical activities designed to support comprehensive assessments of Hierarchical Conditions Category (HCC) risk adjustment data and documentation integrity. Responsible for constructing, planning, and executing on focused coding reviews specifically for Revenue Integrity operations that are aligned to the direction provided by the Revenue Management Risk Adjustment Shared Accountability leadership to promote data integrity for all lines of business (i.e., Medicare Advantage, Medicaid, ACA, etc.). Manages an annual budget of $5 to $6.5 million and leads a nationally dispersed team of approximately 30 to 45 FTEs (direct and indirect reports).
- Operations: Provide oversight, plan and coordinate coding review workload and reporting activities to ensure quality and productivity standards are consistently achieved across all nationally dispersed and remote revenue coding work environments. Collaborate with coding documentation audit program teams to gain insights on operation performance to support strategic decision making and identification of process improvements. Establish and oversee KPIs for Risk Adjustment Coding Review functions. Drive coding (to include external providers) quality, productivity and accuracy through performance measures and monitoring. Participate in development of provider/department performance reports and data analytics for executive leadership. Identify and analyze implications of key changes to the regulatory and policy environment on provider organizations in the areas of risk adjustment and compliance.
- People: Effectively lead a geographically disperse team/organization consisting of 30-45 employees (direct and indirect reports). Build and lead a high performing work environment through strong performance management, open communication, ongoing training and development, and effective engagement activities through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourages creativity, open dialogue on work issues, professional growth, and a consistent, high level of performance. Develop, implement and tracks improvement action plans for process improvement of individuals that fall below established coding review productivity, accuracy, and quality based on standards and thresholds for developing and monitoring team performance and outcomes. Oversee clinician chart audit activities and coordinate operational aspects of clinical chart reviews including identifying and data mining patient lists, coordinating chart provisions with reviewers, communicating results to rendering physicians, tracking, and analyzing findings with the National Compliance Office (NCO) and Risk Adjustment Shared Accountability team. Assess and recommend provider reporting and training to support efforts to optimize efficiencies and processes. Promote continuing education and training for risk adjustment coding review staff related to accurate and compliant coding review for HCC diagnoses and interact with Risk Adjustment Central office to receive data and drive insights.
- Compliance Collaboration: Act as a liaison between Revenue Management and Risk Adjustments team with coding reviewers to align activities, promote objectives (submission completeness, accuracy and truthfulness), and reduce duplication of efforts. Ensure accurate and appropriate policies and procedures are in place and in compliance with CMS and other regulatory guidelines. Coordinate and provide oversight for CMS/Commercial Risk Adjustment Data Validation (RADV) reviews, other ad-hoc risk adjustment reviews, and internal/external for risk adjustment coding reviews.
Minimum twelve (12) years experience coding, to include experience in risk adjustment/HCC coding and physician training required.
Minimum eight (8) years management/supervisory experience in Managed Care, or Medicare Risk Adjustment required.
- Bachelor's Degree in Healthcare Information management or related field, OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED)
License, Certification, Registration
- Coding credential at hire, OR required within one year of hire date; credentialing could be one of the following: 1) CCS - Certified Coding Specialist; 2) CPC (Medical Coding Certification)/Other AAPC Certification - American Academy of Professional Coders, or similar Professional Billing Medical Coder Association.
- Expert knowledge of medical terminology, disease processes and pharmacology.
- Expert knowledge of CMS regulatory rules and coding guidelines.
- Strong communications (written/verbal) and presentation skills.
- Proven influencing skills with proven ability to lead organizational change efforts.
- Must be able to work in a Labor/Management Partnership environment.
- Ten (10) years experience in management consulting or coding senior leadership experience.
- Seven (7) years experience in leadership providing physician education and coder education.
- Experience managing a large multi-regional health system or physician coding pool and/or coding reviewer pool for outpatient and physician services.
- Experience using or implementing Epic or similar enterprise-wide revenue management technology/system.
- Deep expertise in analytics, data analysis, and quality programs.
- Master's degree in Healthcare Information Management, Business, Nursing or related field preferred.
$140K - $160K
$130K - $150K