Supervisor Strategic Risk Adjustment and Quality

Job Summary The role is responsible for developing plans and managing activities in support of Risk Adjustment and Quality/HEDIS. It directs the daily activities of direct reports supporting Risk Adjustment Coding and Quality/HEDIS, assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement, implements strategic and tactical improvements to the Risk Adjustment Coding and Quality/HEDIS processes. Manages information ensuring accurate and efficient projects. Works with departments in risk adjustment, compliance, process improvement, and member/provider satisfaction for all product lines. Recommends and implements process improvements related to quality medical care and service. Serves as a resource regarding government and regulatory audits, accreditation standards, and continuous quality improvement principles. Coordinates audit and accreditation activities on behalf of the organization. Oversees performance of special studies per audits, provider office visits and medical records reviews. Conducts specialized provider office visits for provider education on Risk Adjustment and Quality/HEDIS measures. Oversees the development and implementation of risk adjustment and risk mitigation education related to medical record documentation. Reviews provider office/entity processes for appropriate submission of ICD10, CPT, and HCPCS codes according to guidelines. Essential Responsibilities Perform management responsibilities: hiring and termination decisions, coaching and development, rewards and recognition, performance management, staff productivity; plan, organize, staff, direct and control daily operations; develop and implement policies and programs; may have budgetary responsibility and authority. Provide day‑to‑day managerial oversight for staff responsible for Risk Adjustment coding and Quality/HEDIS activities; ensure continuous improvement of processes and delivery of results; encourage innovation and focus resources; optimize use of resources. Contribute to strategic planning; identify tactical opportunities for improvement, recommend solutions, and develop materials for Risk Adjustment, Quality/HEDIS, and Medical Record Documentation projects; oversee development and execution of processes for complete and accurate diagnosis coding; maintain productivity and team QA scores; report to leadership. Oversee the teams’ processes to conduct multiple types of audits—government and internal—identify gaps, communicate results; use data analysis from office site and/or medical record reviews to improve care, member satisfaction; coordinate with Highmark programs for credentialing, quality improvement, value‑based, care management programs; ensure medical records meet regulatory requirements; consult with providers to ensure gaps and chart deficiency trends are outlined, communicated and staff trained. Participate in cross‑functional initiatives involving staff in different departments or business units and vendors; assess impact of regulatory changes; ensure ongoing compliance; oversee process improvement initiatives including detailed data analysis, process analysis, report generation and documentation. Other duties as assigned or requested. Education Required: Bachelor’s Degree in a Health related field or current state RN/LPN license. Substitutions: 6 years of combined experience with RN/LPN, Risk Adjustment, HCC coding, medical coding/billing HEDIS and/or healthcare related management. Preferred: None. Experience Required: 6 years of combined experience with RN/LPN, Risk Adjustment, HCC coding, medical coding/billing HEDIS and/or healthcare related management. To Include: 3 years with government markets and working within all Compliance and Coding guidelines; 1 year in a management or leadership role. Preferred: 3 years in a clinical nursing role (RN or LPN); 3 years in the Health insurance field; 3 years mentoring others; 1 year project management; 1 year with TQM concepts, techniques, process and outcome measurements experience; 1 year working with HEDIS. Licenses and Certifications Required: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Clinical Research Coordinator (CRC). Preferred: Licensed Practical Nurse (LPN), Registered Nurse (RN). Skills Excellent verbal communication skills. Professional manner and excellent written communication skills, including familiarity with a variety of writing styles. Demonstrated computer literacy and knowledge of information systems and comparative databases; working knowledge of Microsoft Office software. Well‑developed analytical and problem‑solving skills with ability to understand and interpret clinical data. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors, about problem identification, action plan implementation, ongoing monitoring and resolution. Travel Requirement 0% – 25% Physical Demands Lift up to 10 pounds frequently; lift 10‑25 pounds constantly; lift 25‑50 pounds occasionally; rarely perform tasks requiring no lifting. Equal Opportunity Employer Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. #J-18808-Ljbffr Highmark Health