This job is responsible for developing plans and managing activities in support of the Coding and QA area of Risk Revenue Management. Directs the daily activities of direct reports supporting Coding and QA 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 Coding and QA area processes. Manages information that will ensure accurate and efficient Coding and QA area projects. Responsible for working with appropriate departments in the areas of risk adjustment, compliance, process improvement. Recommends and/or implements process improvements related to Coding and QA area. Serves as a resource regarding all coding requirements, policies and processes. Oversees the development and implementation of educational activities related to the Coding and QA area, and medical record documentation to appropriate departments and network provider office sites.
- 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 Coding and QA area 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 Coding and QA area projects related to Revenue Program Management and overseeing the development and implementation of educational opportunities related to Coding and QA area to appropriate departments and network provider office sites. Identify risk associated with inaccurate coding and risk scores which could result in lost revenue, disadvantages relative to competitors and potential CMS sanctions or penalties and work with management to mitigate this risk.
- 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. Consult 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 manages process improvement initiatives to include detailed data analysis, process analysis, report generation and documentation.
- Other duties as assigned or requested.
- 6 years' experience coding quality assurance experience in lieu of Bachelor degree
- Bachelor’s Degree - Registered Nurse
- 5 - 7 years Risk Adjustment, Coding, Quality Assurance
- 3 - 5 years Management or Mentoring a Diverse Professional Staff
- 1 - 2 years Total Quality Management (TQM) Concepts, Techniques, Process and Outcome Measurements
- 1 - 2 years Using Statistics in Order to Analyze Various Reports and Validate Study Methodologies
- 1 - 2 Working Knowledge of the Healthcare Effectiveness Data and Information Set (HEDIS)
- 3 - 5 years in a Health Insurance Field
- 3 years Prior Project Management Experience
LICENSES AND CERTIFICATIONS
- ICD-10 Coding Certification
- 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 Advisers related to problem identification, action plan implementation, ongoing monitoring and problem resolution
- Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data
- The ability to manage multiple projects and successfully mange projects with internal areas and external clients is required
- Strong leadership, coaching, mentoring abilities that will develop/maintain a high-performing team
- Must be able to take charge of and be accountable for management of staff working on multiple projects to ensure corporate deadlines and objectives are met. Ability to motivate high performance and demonstrate abilities in relationship management
Language Requirement (other than English)?
0% - 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Teaches/Trains others regularly
Most of the time
Travels regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (Sales employees)
Does Not Apply
Physical Work Site Required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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