The Coding Precision Program Manager manages the Coding Precision program in the Prior Authorization, Provider Audit and OPL department including achieving defined productivity and quality metrics, reporting division activities to the Senior Director, responding to related interdepartmental and provider inquiries and guaranteeing that all work is in compliance with internal protocols. The Manager ensures that claims accurately reflect the appropriate risk adjustment.
Develops and/or revises program policies, procedures, and workflows as required.
Sets goals and objectives consistent with department and corporate goals, manages inventory and ensures that all activities are performed in accordance with departmental policies and procedures.
Develops and submits program activity reports, including monthly and quarterly reviews, anomalies, projected results, or changes in processes to department Senior Director.
Collaborates with department Data Specialist and Corporate Analytics program manager to obtain Phase 1 and Phase 2 Algorithm files from Corporate Analytics and format for use in diagnosis code review.
Identifies target diagnosis codes.
Identifies claims associated with targeted diagnosis codes and requests medical records for review.
Working independently performs on-site and, rarely, desk audits of medical records.
Confirms presence of target diagnoses and solicits and receives physician/provider sign-off to update claim information.
Updates claim information in Facets per protocol.
In conjunction with Corporate Analytics, evaluates outcome of Phase 1 and Phase 2 Algorithms.
Regular and reliable attendance is an essential function of the position.
Bachelors Degree in a health care discipline or equivalent combination of education and experience.
Coding certification (CPC, CCS, etc.)
Degree in a nursing or health information management.
5+ years related experience in an acute care or health insurance environment.
2+ years experience with claims or medical record audit.
Experience with FACETS or other billing and accounts receivable or claims payment system.
Experience developing and implementing claims and/or medical record review programs.
Competencies, Skills, and Attributes:
Strong analytical and problem solving skills.
Strong oral and written communication skills.
Ability to interact within all levels of the organization as well as with external contacts.
Demonstrated strong organization and time management skills.
Ability to work in a fast paced environment; ability to multi-task.
Ability to work independently, at times off-site.
Experience with standard Microsoft Office applications, particularly MS Excel and MS Word.
Valid driver’s license with available automobile to travel to provider sites.
Working Conditions and Physical Effort:
Fast paced office environment.
Requires extended periods of time at a computer terminal.
Requires periodic transport of approximately 20 pounds of materials via rolling briefcase.
Boston Medical Center HealthNet Plan - 13 months ago