Manager, Risk Adjustment Coding

About the role

The Risk Adjustment (RA) Manager reports to the Director of Burden of Illness (BOI) and performs duties to conduct the day-to-day management of the MRA Team Supervisors and team functions by communicating with other operational departments and provider offices. This role participates in the development, implementation, and performance of workflows for reviewing electronic medical records aimed at improving the health and well-being of patients through appropriate identification of chronic disease conditions. The position collaborates with all areas of the organization to ensure success of value-based coding initiatives such as provider engagement, education, prevalence rates, documentation compliance, and medical margin. It supports and further enhances the data and reporting model to capture and optimize ICD-10 reporting to payers to improve quality for patients and reduce healthcare costs.

This position manages risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

• Prospective medical record review
• Concurrent outpatient claim diagnosis coding
• Retrospective medical record and provider response reviews

Responsibilities

• Serve as subject matter expert for proper risk adjustment coding and CMS data validation
• Provide daily management of department staff and provide feedback to the Director of BOI on exceptional and/or substandard performance
• Oversee and ensure completion of all efforts associated with hiring, interviewing, onboarding, recognition, and discipline of staff
• Develop provider performance measures on important aspects of care and service through data reviews and data-driven analysis
• Provide ongoing feedback to staff on areas of success and improvement opportunities
• Ensure that all members of the team are following official guidelines, policies, and standard procedures
• Counsel staff on actions required to meet minimum performance requirements
• Provide or arrange for necessary knowledge-based resources required by the department staff to meet quality and production standards
• Contribute to the reporting for reassessment of chronic conditions, provider address rates, coder variability, and other risk adjustment coding-related measure trends
• Participate in identifying and developing technology to enhance risk adjustment operations and accuracy
• Stay updated on changes to Medicare guidelines, coding regulations, and reimbursement methodologies to ensure compliance and accuracy in coding practices
• Develop and lead coding education and training initiatives for staff to promote consistent and accurate coding practices across the organization
• Research best practices in risk adjustment coding and review the professional literature for coding updates, maintaining currency in coding
• Evaluate, research, and recommend enhancements to the risk adjustment program and internal coding guidelines
• Develop and implement new workflows and policies and procedures as needed to support new and existing department initiatives, audits, and projects
• Lead workgroups and manage project deliverables for department initiatives, audits, and provider communications
• Keep department Director apprised of project activities through regular written and oral status reports and proactively identify risks that may hinder project success

Qualifications

• Bachelor’s degree or 3 years of equivalent related work experience
• Current active coding credential through AAPC or AHIMA required; preference given to those with CRC designation
• Minimum of three (3) years coding experience directly related to Hierarchical Condition Category (HCC) coding
• Minimum of two (2) years experience in a lead/senior role
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and healthcare reimbursement systems, including comprehensive understanding of ICD-10-CM
• Advanced skills for use of MS Office (Excel, Word, Access, and PowerPoint)
• Demonstrated ability to utilize a variety of electronic medical records systems
• Ability to manage significant workload and to work efficiently under pressure meeting established deadlines with minimal supervision; strong time management skills
• Must possess high degree of accuracy, efficiency, and dependability
• Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization both verbally and in writing
• Demonstrated organizational and problem-solving ability
• Demonstrated experience in project completion, educational program development and/or group presentation
• Commitment to maintaining confidentiality and adhering to ethical coding standards

Physical Demands

• Sedentary work
• Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects
• Repetitive motion with substantial movements of the wrists, hands, and/or fingers
• The worker must have close visual acuity to perform activities such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading
• Ability to lift up to 15 lbs independently and up to 50 lbs with assistance

Compensation Range

$85,159.00 to $127,738.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.