Summary: Responsible for hiring,
training and developing staff to support the PHP Risk Adjustment program. Supervises Risk Adjustment Educators and Risk
Adjustment Program Support Coordinator to ensure department’s program is
effective and meets the needs of client-providers. 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.
A. ORGANIZATIONAL SAVVY
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.
- Collaborates and communicates with internal
and external facing departments to align strategies which reflect current Risk
Adjustment program services, development needs and organizational goals.
B. DECISION MAKING/JUDGEMENT
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,
realistic plans, sets goals, aligns plans with company goals, plans for and
manages resources, creates contingency plans, coordinates/cooperates with
- 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
D. PEOPLE MANAGEMENT
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
- 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
E. CUSTOMER FOCUS
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.
- Develop high level, interactive relationships
with client practices in order to maintain engagement and appropriate staff assignments.
- Provide or arrange coverage support to
practices when assigned risk adjuster educator is not available.
F. JOB KNOWLEDGE
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.
- Other duties as assigned.
- Education: Associates or Bachelors’ degree
Coder Certification (CPC) required.
auditing of clinical data in physician offices or medical facility required.
- Minimum three years’ experience in a medical
office, health plan or hospital system working with electronic medical records.
- 2 years supervisory experience; prefer
experience supervising risk adjustment staff and programs.
- Knowledge of health care insurance claims
practice and compliance.
- Knowledge of Medicare rules and guidelines.
- Knowledge of Claims Coding (CPT, HCPCS,
Revenue Codes, ICD-9/ICD-10, UB92/HCFA 1500).
- Knowledge of risk adjustment categories and
- 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
- 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
- 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
- A valid unrestricted Colorado drivers’
license. Reliable and insured vehicle.
- Mobile Device for work purposes as defined by
the company policies and procedures.
Demands The physical demands described here are representative of those
that must be met by an employee to successfully perform the essential functions
of this job. Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential functions. While performing the
duties of this Job, the employee is regularly required to sit; use hands to
finger, handle, or feel and talk or hear. The employee is frequently
required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or
crawl. The employee is occasionally required to climb or balance. The
employee must regularly lift and/or move up to 25 pounds. Specific vision
abilities required by this job include close vision and ability to adjust
Work Environment: The work environment
characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities to perform
the essential functions. The noise level in the work environment is