Position Summary: Provides leadership and management of coding, auditing, and education functions in the IPA practices. Responsible for hiring, training and developing staff, implementing policies and procedures, establishing goals, objectives, and all of the benchmarks for the department. Responsible for chart audits, encounter forms, reimbursement analysis and coding education for providers, billing office and clinics (includes the residents). Primary contact for physicians and staff for population acuity coding questions, issues and new services.Works in collaboration with other PHP external-facing departments (PR, Quality, Care Coordination) and support departments (Client Decision Support and IT) to ensure program implementation, data collection and performance reporting that assists practices in coding more effectively and accurately to maximize IPA revenue. Obtains assistance from community experts, plans education and serves as a mentor/trainer to internal and external customers and vendors.
Operates within the organization's formal and informal structures, builds allies and relationships across departments, uses allies to build consensus and create results, is appropriately diplomatic, understands others' roles and perspectives, can sell projects and ideas across the organization.
- Recognize present and past operations, trends and costs, estimated and realized revenues and expenses, administrative commitments and obligations incurred.
- Coordinates with quality department, medical management staff and medical directors to achieve client initiatives and goals.
- Analyzes data in order to evaluate the outcomes and effectiveness of client programs that are focused on population acuity. Works with leadership to interpret this information and respond as appropriate.
- Collaborates and communicates with internal and external facing departments to align strategies which reflect current Risk Adjustment program services, development needs and organizational goals.
Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, communicates decisions to others.
- Evaluates practice and staff performance and satisfaction to ensure decisions: are supported by information collected from appropriate sources; meet the needs of departments involved; are communicated in a timely manner; and reflect timely, collaborative, thoughtful solutions.
Develops realistic plans, sets goals, aligns plans with company goals, plans for and manages resources, creates contingency plans, coordinates/cooperates with others.
- Develops plan for staffing, training, evaluating and budgeting appropriate levels of support for the current and future plans for the Risk Adjustment program.
- Determines methods for evaluating and reporting resource needs and coverage during time off, turn over, etc.
- Develops and measures methods to understand and improve interrator reliability surrounding record reviews and education messaging.
- Promotes continuing process improvement and innovation for department and organization.
- Recommends, develops, and updates strategic long-and short-range plans to support the client's philosophy and goals.
- Works in conjunction with Joint Operations and BOM in charting and implementing the clients’ strategy as it pertains to population acuity capture.
Defines roles and responsibilities, applies clear/consistent performance standards and provides feedback and coaching. Handles performance problems decisively and objectively, provides guidance and assistance to improve performance, rewards hard work and risk taking, motivates, challenges and develops employees, delegates effectively.
- Completes regularly scheduled one on ones with Risk Adjustment staff to discuss current objectives, goals, obstacles and assistance needed to continue to grow within the department.
- Provides materials, answers questions and responds to requests from both internal and external partners.
- Supervises risk adjustment educators and program support staff to ensure work is timely and complete.
- Identifies and communicates to leadership (director) any additional training needs for department to ensure integrity of services provided.Manages Risk Adjustment Education department activities. To include: management of standard and ad hoc financial, utilization and operational analysis and reporting; monthly financial statements; and variance analysis and organization of plan statements. Responsible for the timely dissemination of accurate reporting to internal and external clients.
Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.
- Acts as a primary resource for PHP staff, physicians and practice staff to answer questions regarding risk adjusting coding and Medicare coding guidelines and code updates.
- Develops high level, interactive relationships with client practices in order to maintain engagement and appropriate staff assignments.
- Provides or arranges coverage support to practices when assigned risk adjuster educator is not available.
- Assists in the ongoing development and implementation of the HCC risk adjustment training program used to educate physicians and office staff on coding techniques that accurately document and capture patient acuity to the highest degree of specificity while adhering to IPA ethical standards and Medicare guidelines.
Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues.
- Understands and provides staff training regarding the ongoing development and implementation of the Risk Adjustment program, including planning resources and assignments to meet client needs.
- Researches and/or uses department, CMS and UnitedHealthcare materials to support training and ensure compliance.
Plans for and uses resources efficiently, always looks for ways to reduce costs, creates accurate and realistic budgets, tracks and adjusts budgets, contributes to budget planning.
- Other duties as assigned.
- Bachelor’s Degree in finance, economics, health administration, business administration or related field required. Masters’ Degree preferred.
- Professional Coder Certification (CPC) required.
- Minimum three years’ of management experience; prefer experience supervising risk adjustment staff and programs.
- Previous auditing of clinical data in physician offices or medical facility required.
- Knowledge of health care insurance claims practice and compliance.
- Knowledge of Medicare rules and guidelines.
- Knowledge of CPT, ICD-9, ICD-10, DRG, APC/ASC, HEDIS, AAPCC, Medicare services and reimbursement methodologies, revenue codes and RBRVS.
- Knowledge of risk adjustment categories and hierarchy.
- Knowledge of MS Office Suite, other software programs and internet based applications as needed to fulfill position duties.
- Skilled in synthesizing data and questions to communicate a cohesive educational training program.
- Skilled in presenting and explaining data in a clear, concise manner.
- Skilled in interpreting Medicare rules and changes.
- Skilled in responding to practice inquiries in a timely and accurate manner.
- Skilled in working collaboratively with various parties to communicate an accurate and meaningful reporting package for practices.
- Able to work effectively with physicians, practice staff, health plan/other external parties and PHP multi-disciplinary team to streamline efforts to meet Risk Adjustment goals.
- Able to work with sensitive data and relay potential issues or concerns in a diplomatic manner.
- Able to multi-task and meet deadlines.
- Able to work with external parties to incorporate data elements into reporting package.
- Able to communicate findings in a clear, concise manner, both internally and externally.
- Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures.
- A valid unrestricted Colorado drivers’ license. Reliable and insured vehicle.
- Mobile Device for work purposes as defined by the company policies and procedures.