Director, Clinical Excellence/BOI

About the Role

The Director of BOI reports to the Director of Quality Programs and is responsible for overseeing, coordinating, or performing data reviews and data-driven analysis to forecast and evaluate the performance of the risk adjustment program. This role involves refining annual risk adjustment strategies to achieve optimal performance, fostering vendor and carrier relationships, and identifying areas of opportunity through reporting and workflow improvements. The Director collaborates across the organization to ensure the success of value-based coding initiatives, including provider engagement, education, prevalence rates, coding opportunities, documentation compliance, and medical margin.

The Director is tasked with improving the Risk Adjustment department through innovative technologies, leading and growing the team, and exploring future programs to enhance the organization’s position in Value-Based Programs.

Responsibilities

• Ensure compliance with all applicable Federal, State, and County laws and regulations related to coding and documentation guidelines for Risk Adjustment.
• Develop, train, and lead staff to review medical records, including patient history, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify:
  • Diagnosis codes are supported by documentation and comply with ICD-10-CM Guidelines for Coding and Reporting.
  • Diagnosis codes for chronic or major medical conditions are captured and submitted within permitted timeframes.
  • Unsubstantiated diagnosis codes are submitted to carriers within timely guidelines.
• Review clinical indicators and query providers to capture the severity of illness of patients.
• Measure provider performance on key aspects of care and service through data reviews and analysis.
• Communicate and coordinate reviews with the RA Provider Educator and Support Services for provider training sessions.
• Facilitate and coordinate reporting to leadership as requested.
• Manage the BOI Team with an emphasis on excellent service to patients, providers, and internal/external customers.
• Communicate defects in reporting systems or databases to supervisors and IT, suggest improvements, and track completion to ensure revenue capture.
• Confirm code capture and proper RAF calculations by carriers.
• Provide reporting for revalidation of codes, accept/reject rates, code trends, and areas of opportunity (by carrier, provider, POD, etc.).
• Assist in identifying and developing technology to enhance risk adjustment operations and accuracy.
• Support health plan ASM/EDS data submission or reconciliation.
• Provide clear, concise, and professional communication to varying audiences.
• Demonstrate excellent time management, attend and contribute to required meetings (may include travel and hours outside standard business hours or above 40 hours per week).
• Train new leaders, provide ongoing education to existing staff, and perform quality reviews with feedback for the Risk Coding team.

Supervisory Responsibilities

• Directly supervise assigned employees in the Risk department.
• Carry out supervisory responsibilities in accordance with organizational policies and applicable laws, including interviewing, hiring, training, planning, assigning, and directing work.
• Appraise performance, reward and discipline employees, and address complaints and resolve problems.

Qualifications

• Enrolled in or completed a Bachelor’s degree from a four-year college or university.
• One to two years of related experience and/or training, or an equivalent combination of education and experience.
• Flexibility in work hours, multitasking, and excellent computer skills.
• CRC and/or CPC certification preferred.

Skills

• Adaptability: Maintain effectiveness in varying environments and with different tasks, responsibilities, and people.
• Analysis/Problem Assessment: Secure relevant information, identify key issues, and recognize cause-effect relationships.
• Communication: Express ideas effectively in individual and group situations, adjust language for the audience, and demonstrate good listening skills.
• Compassion: Prioritize patient/person interests, avoid harm, deliver proper care, and maintain confidentiality.
• Compliance: Complete required compliance training and demonstrate understanding of the Code of Conduct.
• Dependability: Meet commitments, deliverables, and deadlines; work independently; accept accountability; handle change; and meet attendance/punctuality requirements.
• Follow-up: Monitor results of delegations, assignments, or projects.
• Initiative: Influence events to achieve goals, self-start, and take proactive action beyond requirements.
• Integrity: Maintain and promote social, ethical, and organizational norms in business activities.
• Judgement/Problem Solving: Recognize problems, gather information, seek input, address root causes, and make timely decisions.
• Patient Service Orientation: Proactively develop patient/customer relations, understand needs, provide solutions, and advocate for customer satisfaction.
• Practical Learning: Assimilate and apply new job-related information in a timely manner.
• Quality Orientation/Attention to Detail: Focus on detail and accuracy, commit to excellence, monitor quality, and find root causes of problems.
• Results Driven & Execution: Meet or exceed individual/department goals, set priorities, organize time, and take responsibility for results.
• Teamwork/Collaboration: Work effectively with teams or outside formal authority to achieve organizational goals, respect contributions, and value opinions.
• Technological/Professional Knowledge: Achieve satisfactory technical/professional skills in job-related areas and stay updated on developments.
• Work Standards: Set high goals or standards for self, team, and organization; strive for excellence rather than accepting average performance.

Additional Requirements

• Language Skills: Read and interpret documents (safety rules, operating instructions, procedure manuals), write routine reports and correspondence, and speak effectively before groups.
• Mathematical Skills: Calculate figures such as discounts, interest, commissions, proportions, percentages, and basic algebra/geometry concepts.
• Reasoning Ability: Solve practical problems with limited standardization and interpret instructions in written, oral, diagram, or schedule form.
• Computer Skills: Proficient in Microsoft Excel, Word, Outlook, ADP Payroll systems, and knowledge of computers, fax, portals, uploading/downloading, and EMR systems (e.g., Athena).

Physical Demands

• Regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; and talk or hear.
• Frequently required to stand and walk.
• Occasionally required to stoop, kneel, crouch, or crawl.
• Occasionally lift and/or move up to 25 pounds.
• Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment

• The noise level in the work environment is usually moderate, depending on office business activity.

Pay

The anticipated base salary range for this position is $137,150.00 to $205,724.00. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.