A Brief Overview
The Risk Adjustment Consultant is responsible for designing and deploying Risk Adjustment processes and initiatives to meet the needs of the Medicare and Commercial lines of business. The Consultant will work in collaboration with other business leaders and clinical leadership, within and outside of Stanford Health Care, to develop and implement comprehensive strategies to manage and drive improvement in end-to-end clinical documentation process, from on-boarding to claims submission and reporting.
Stanford Health Care
What you will do
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patients rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings. Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).
Conducts all risk adjustment activities, including developing process flows, establishing, tracking, and meeting deadlines, managing vendor execution within contract requirements, coordinating all submission and reconciliation with internal and external stakeholders, and ensures all regulatory requirements related to risk adjustment are met.
Analyzes medical record documentation and develops and automates the reporting of findings that differentiate deficiencies of common-cause variations and special-cause variations.
Identifies high-priority educational content and partners with managers and supervisors with the development of professional quality educational programs for physicians and staff to disseminate information about new codes and/or reimbursement requirements in response to federal and state regulations, review findings, or inquiries by physicians and staff.
Performs prospective and retrospective compliance reviews of coding to ensure the documentation of billable professional fees meets government and commercial payer regulations and SHC guidelines.
Conducts root-cause analyses, generates improvement hypothesis, and tests interventions, which may include but is not limited to providing one-on-one and/or group training to billing and coding staff, providers and others as necessary or requested.
Seeks and interprets Physician's Current Procedural Terminology (CPT) and ICD publication updates, including government and professional publications to keep current.
Serves as resource to staff on coding questions for new or existing services.
Stays current with Medicare and Medi-Cal publications for healthcare providers to include all reporting and reimbursement updates, and determines their applicability to SHC.
Extracts relevant data elements from various systems and other sources for business planning and analysis including clinical volume, facility metrics, reimbursement methods, financial performance/projections, market share, population demographics and projections.
Develops detailed, multi-year business plan information for proposed programs including goals, specific actions, timelines, metrics and measures for on-going tracking, investment requirement, and economic performance over time.
Anticipates and translates clinical and operational needs into technical and analytical requirements.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Bachelor's degree in a work-related discipline/field from an accredited college or university.
Master’s degree preferred.
Required Knowledge, Skills and Abilities
Ability to apply judgment and make informed decisions
Ability to communicate complex concepts in simple form to cross-functional departments or teams
Ability to conduct analysis and formulate conclusions
Ability to foster effective working relationships and build consensus
Ability to work effectively both as a team player and leader
Ability to work well with individuals at all levels of the organization
Ability to plan, organize, prioritize, work independently and meet deadlines
Ability to solve technical and non-technical problems
Knowledge of and ability to research and apply laws, regulations and billing rules, including CMS manuals and Medi-Cal rules
Knowledge of local, state and federal regulatory requirements related to areas of functional responsibility
Knowledge of Medical Terminology and transcription process
Knowledge of new technologies (in specific field) and maintain and stay abreast of updates and changes
Knowledge of computer systems and software used in functional area
Knowledge of decision support systems, database and other software and analytical tools
Licenses and Certifications
CPC and/or CCSP - Certified Professional Coder or
RHIT - Registered Health Information Technician or
RHIA - Registered Health Information Administrator
Physical Demands and Work Conditions
Blood Borne Pathogens
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:
Know Me: Anticipate my needs and status to deliver effective care
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.