RADV (Risk Adjustment Validation) Nurse- Quality Management

POSITION SUMMARY/RESPONSIBILITIES

Manages, supervises, and assists Sr. Manager Clinical Process Improvement of Quality Management and Accreditation with oversight assigned staff to facilitate high-quality, cost-effective care for Community First membership. The RADV Nurse will enhance consistency and efficiency by collaborating with Providers to meet goals for Hierarchical Condition Categories (HCC) Ratio. Spearhead initiatives for Risk Adjustment improvement, develop recommendations for Risk Adjustment plans, and design tools and databases to gather relevant data for assigned provider groups. Works closely with various departmental teams and their leaders in a matrix structure. Additionally, the RADV Nurse will provide direction and support to provider Medical Coding Analysts and Community First cross-functional team members regarding Risk Adjustment issues. Creates customized reports based on analysis of data for dissemination and makes recommendations to improve the quality of operational/clinical performance and health outcomes. Provides ongoing management of data collection systems and the development of procedures for monitoring, validating, and reconciling data for accuracy. May serve as a leader/facilitator of process improvement efforts. Provides oversight of and performs functions of review, investigation and analysis of member level clinical care data and provider performance as it compares to standards of care.

EDUCATION/EXPERIENCE

Graduation from an accredited school of professional nursing is required. Bachelor's degree in nursing, clinical informatics, or other health care related field is preferred. Over five years of experience in the healthcare industry, including at least one year of ICD-10 coding. Familiarity with CMS HCC Model and Guidelines, as well as ICD-10 Guidelines, is essential. Experience in data analysis and preparation of QI or related reports is preferred. Excellent communication and interpersonal skills required. Quality Management certification such as CPHQ or CHCQM is preferred. Working knowledge of continuous process improvement principles and standard coding products is preferred. Proficiency in health information systems, electronic health records (EHRs), HEDIS, RADV, and claims data analysis is a plus.

LICENSURE/CERTIFICATION

• Current licensure as a Registered Nurse in the State of Texas is required.
• Coding certification within 2 years of employment (e.g., Certified Professional Coder - CPC, Certified Coding Specialist - CCS)