Manager, Coding & Quality Assurance

Job ID: J115287
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 26, 2018

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Description

JOB SUMMARY 


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.
 

ESSENTIAL RESPONSIBILITIES

  • 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.


REQUIRED EDUCATION

  • Bachelor's Degree

Substitutions 

  • 6 years' experience coding quality assurance experience in lieu of Bachelor degree

PREFERRED EDUCATION

  • Bachelor’s Degree - Registered Nurse

EXPERIENCE

Required

  • 5 - 7 years Risk Adjustment, Coding, Quality Assurance
  • 3 - 5 years Management or Mentoring a Diverse Professional Staff

Preferred

  • 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

Required

  • CPC, AAPC


Preferred

  • ICD-10 Coding Certification

SKILLS

  • 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)?  
None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS

Position Type

Office-Based

Teaches/Trains others regularly

Most of the time

Travels regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (Sales employees)

Does Not Apply

Physical Work Site Required

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

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.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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