This job is responsible for developing plans and managing activities of the coders and coder/clinicians in support of HCC Coding, HEDIS, and Quality for Risk Revenue Management. Directs the daily activities of direct reports supporting HEDIS, Quality, and HCC Coding activities. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement. Implements strategic and tactical improvements to the HEDIS, Quality and Coding processes. Manage information that will ensure accurate and efficient HEDIS, Quality and HCC Coding projects. Responsible for working with appropriate departments in the areas of risk adjustment, compliance, process improvement and member/provider satisfaction for all product lines. Recommends and/or implements process improvements related to comprehensive and CMS compliant office visits, quality medical care, and complete documentation. Oversees the development and implementation of educational activities related to HEDIS, Quality, Medical Record HCC Coding, and medical record documentation to appropriate departments and network provider office sites. Serves as a resource regarding accreditation standards including NCQA standards and continuous quality improvement principles. May coordinate accreditation activities on behalf of the organization. Oversees the Performance of special studies per audits, conducting office site visits and medical records reviews, ensuring resolution of member/provider dissatisfactions in timely manner.
- Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plan, organize, staff, direct, and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Provide day-to-day managerial oversight for staff responsible for HEDIS, Quality and Coding activities. Ensure continuous improvement of processes and delivery of results within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimize the use of resources in assigned area using proven resource management techniques.
- Contribute to the department’s strategic planning efforts by identifying both strategic and tactical opportunities for improvement and recommending solutions, especially directed at HEDIS, Quality and Medical Coding/Medical Record Documentation projects related to Revenue Program Management and overseeing the development and implementation of educational opportunities related to HEDIS, Quality, Medical Record Coding, and medical record documentation to appropriate departments and network provider office sites.
- Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Oversee Revenue Program Management medical record reviews to ensure medical coding and medical record documentation is complete and accurate. Oversee the development and implementation of QA standards for all medical coders
- Oversee the processes to conduct annual audits, identify gaps, repeating issues and communicate results in provider office sites with data analysis from office site and/or medical record reviews to (a) continually improve the care, service to members and patient satisfaction; (b) coordination with the credentialing and quality improvement programs to achieve and maintain accreditation, and (c) ensure medical records meet regulatory requirements. Consults with providers as needed to ensure identified gaps, or chart deficiency trends are outlined, communicated, discussed and provider staff trained on correct procedures.
- Participate in initiatives requiring cross-functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners.
- Assess the impact of potential or actual regulatory changes impacting the assigned area. Ensure ongoing compliance in all activities within the assigned area.
- Oversee the development and manage process improvement initiatives to include detailed data analysis, process analysis, report generation and documentation.
- Other duties as assigned or requested.
- Bachelor's Degree in a health-related field or 6 years of experience as a registered nurse with managerial, process improvement, healthcare insurance and/or medical coding experience
- ICD-10 Coding Certification
- 5-7 years of HCC Coding experience
- 3-5 years of Coding experience with a ICD-10 Coding Certification (CPC, CCS, or RHIA)
- 3-5 years of experience working with government markets and working within all Compliance and Coding Guidelines.
- 3-5 years of leading and/or supervising employees
- 1-3 years of prior project management experience
- LPN or RN
- 3-5 years of clinical nursing experience in a hospital or office setting (RN or LPN)
- 1-2 years of Total Quality Management (TQM) concepts, techniques, process and outcome measurements experience
- 1-2 years of experience working knowledge of the Healthcare Effectiveness Data and Information Set (HEDIS)
- 3-5 years in a health insurance field
- 3-5 years of mentoring others
- 1-2 years of statistics experience preferred in order to analyze various reports and validate study methodologies
- Registered Nurse
- Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution
- Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
- Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data
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