Director, Provider Education & Risk Adjustment

Responsibilities

• Develop and maintain collaborative relationships with assigned providers/practices within Elderplan Network.
• Coordinate and present education of providers/practices related to risk adjustment, coding, and clinical documentation improvement.
• Assess workflow processes in physician practices that impact the ability to maximize Health Plan revenue achieved through the various risk adjustment payment models.
• Identify trends and barriers that interfere with correct coding and documentation practices in the physician practice sites, including but not limited to workflow, electronic health records, and clearinghouses.
• Adhere to CMS coding and documentation guidelines.
• Analyze medical record documentation and coding through a chart review process that identifies incorrect coding, coding lacking supporting documentation, and missed opportunities to capture risk adjustment diagnoses and associated revenue.
• Analyze and distribute reports to providers that summarize their performance related to coding and documentation and risk adjustment.
• Develop and implement strategic action plans based on findings of assessment of physician practice workflows and medical record documentation reviews.
• Maintain confidentiality of chart review results and member information.
• Maintain a current and in-depth knowledge of CMS guidelines related to risk adjustment, coding, documentation, as well as knowledge of new models of risk adjustment that impact Health Plan revenue.
• Track all educational activities and trends and patterns of providers/practices.
• Assist practice with integration of correct coding and documentation standards into workflow.
• Troubleshoot issues that impact the integration of correct coding and documentation and maximization of Health Plan revenue.
• Monitor ongoing performance of physicians and practices and report findings to the providers, practice administrators, and Risk Adjustment management. Identify sites within the network to offer public education on coding and documentation and provide classes on a regular basis.
• Identify and document best practices related to coding, documentation, and workflow and share with practice administrators and risk adjustment physician educator staff.
• Collaborate with practices that have entered into shared savings arrangements with Elderplan and assist them with identifying strategies that will improve their quality of patient care and maximize risk adjustment revenue.
• Assist Vice President in development of education objectives and programs.
• Collaborate with Risk Adjustment management staff in the development and implementation of the annual Risk Adjustment prospective campaigns.
• Collaborates with Network Management, Reimbursement, Claims, and other Health Plan departments as required.
• Ensures appropriate staffing and resources to support department/agency services. Monitors productivity throughout the year and participates in annual budget preparation.
• Interviews and participate in the selection process for qualified staff in collaboration with Human Resources and Senior Leadership.

Qualifications

• Bachelor's Degree required or comparable work experience will be considered.
• Minimum 5 years of experience in professional services, including practice management, nursing, clinical documentation improvement or quality audit.
• 2-3 years of teaching experience in a clinical setting preferred.
• 2-3 years of progressive leadership experience preferred.
• Extensive knowledge of coding and documentation requirements including ICD-10-CM, CPT-4, and HCPCS. In-depth knowledge of medical terminology, anatomy and physiology, pharmacology, and pathology required.
• A general understanding of Health care insurance and Medicare managed care is highly preferred for this position.
• Excellent verbal and written communication skills, analytical skills, and organization skills required.
• Extensive problem-solving experience is required.
• Experience working with physicians and physician practices. Goal-oriented and experience with development and implementation of action plans.
• Excellent customer service required.
• Ability to interact with public in a diplomatic and tactful manner and represent the Health Plan effectively.
• Ability to manage relationships with assigned practices and maintain records of all activities.
• Ability to develop action plans as required.
• Proficient computer skills.
• Self-motivated with the ability to work with minimal supervision.