Directs the activities of the Medicare Risk Adjustment Department to ensure Medicare coding is accurate and correct.
• Accountable for problem solving and continuous improvement of department operations. This includes acting as a mentor and overseeing the professional growth of the direct and indirect reports (supervisor and staff under the supervisor).
• Develops and directs the implementation of the Medicare Risk Adjustment strategic work plan approved by the Medicare Department.
• Manages customer expectations and develops or modifies existing processes and reports to meet those expectations.
• Manages vendors relations and activities to meet department and revenue management goals. Develops and implements a business plan to supplement the vendors revenue management activities by utilizing internal staff.
• Oversees the internal staff audits and the development and implementation of department plans to assure that staff is applying correct coding guidelines.
• Oversees the acquisition of medical records and coding extraction process in support of CMS RADV audits. Also supports the Medicare Financial Audits related to HCC coding.
• Identifies and manages issues around HCC training and quality integrity audits related to HCC coding.
• Implements department policies regarding medical coding guiding principles and rules.
• Develops an education plan for staff in the Department and is fluent on ICD-10 coding.
• Applies process improvement tools and techniques to department processes. Assists the team lead and staff in the identification and improvement of opportunities, both within the department and those that are inter-departmental.
• Functions as key liaison and provides support on revenue management initiatives, best practice principles around contract negotiations efforts and policy/process to affect organizational change to improve efficiency and profitability.
• Identifies opportunities for reducing administrative or benefit expense for Medicare.
• Assists in the identification and implementation of cost containment efforts on a continuing basis to meet the financial and performance goals of the Medicare department in regards revenue management opportunities. Conducts appropriate cost benefit analyses as necessary and oversees implementation of these projects and opportunities
• Manages departmental expense and work through the budget process.
• Works with all levels of management and staff, acts as subject matter expert in HCC coding, familiar with the Centers for Medicare and Medicaid Services (CMS) guidance related to Risk Adjustment Data Validation Audits, familiar with current developments in insurance and health care, provides leadership for change, and monitors tasks, priorities and customer commitments.
• Maintains knowledge of all relevant Centers for Medicare and Medicaid Services (CMS) Regulatory Reimbursement and Compliance Regulations for Medicare Advantage Plans.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Bachelor’s Degree in Health Care, RHIT with CPC, CPC-P or CPC- I certifications. MS preferred with CPC, CPC-P or CPC- I certifications.
• Minimum of ten years of progressive experience in management capacity, hospital coding and in particular experience in HCC coding.
• Experience in physician /provider – coding and compliance training programs.
• Experience in presentations at conferences and publications preferred.
• Must possess excellent written, verbal communication, presentation, training, problem solving, analytical skills and the ability to deal effectively with all levels of personnel in the health care industry.
• Understanding the functionality and use of risk adjustment software products.
• Strong knowledge of claims systems and code review.
• Excellent PC skills including Excel, Word, PowerPoint, Access and Lotus Notes.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Excellus BlueCross BlueShield - 14 months ago