Quality Control Supervisor

Company: Highmark Inc. Job Summary This job is responsible for developing plans and managing activities in support of Risk Adjustment and Quality/HEDIS. 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 that will ensure accurate and efficient projects. Responsible for working with appropriate departments in the areas of risk adjustment, compliance, process improvement and member/provider satisfaction for all product lines. Recommend and/or implements process improvements related to the potential of quality medical care and service. Serves as a resource regarding government and regulatory audits, accreditation standards, and continuous quality improvement principles. Co‑ordinates audit and accreditation activities on behalf of the organization. Oversees the Performance of special studies per audits, conducting 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, risk adjustment, Quality/HEDIS. Review of provider office/entity process for appropriate submission of ICD10, CPT, and HCPCs codes according to government and coding guidelines. Essential Responsibilities Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day‑to‑day operations of the department; develop and implement policies and programs as necessary; 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 within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimize the use of resources in assigned area using proven resource management techniques. Contribute to the department’s strategic planning efforts by identifying tactical opportunities for improvement, recommending solutions, and developing materials especially directed at Risk Adjustment, Quality/HEDIS, and Medical Record Documentation projects related to the development and implementation of educational opportunities. Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Oversee the development and implementation of complete, accurate, and fair QA standards for all medical coders. Maintain Productivity and team QA scores and report to leadership. Oversee the teams’ processes to conduct multiple type of audits, government and internal, identify gaps, repeating issues and communicate results in provider office sites with data analysis from office site and/or medical record reviews to (a) continually improve the care, service to members and patient satisfaction; (b) coordination with other Highmark programs for credentialing, quality improvement programs, value based programs, care management programs, to achieve high caliber results, and (c) ensure medical records meet regulatory requirements. Consults with providers as needed to ensure identified gaps, or chart deficiency trends are outlined, communicated, discussed and provider staff trained on correct procedures. Participate in initiatives requiring cross‑functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners. Assess the impact of potential or actual regulatory changes impacting the assigned area. Ensure ongoing compliance in all activities within the assigned area. Oversee the development and manage process improvement initiatives to include 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 Experience 3 years in a clinical nursing role, in a hospital or office setting (RN or LPN) 3 years in the Health insurance field 3 years of mentoring others 1 year of Project management 1 year with Total Quality Management (TQM) concepts, techniques, process and outcome measurements experience 1 year working with Healthcare Effectiveness Data and Information Set (HEDIS) Licenses or Certifications Required (any of the following): Certified Professional Coder (CPC) Certified Coding Specialist (CCS) Registered Health Information Administrator (RHIA) Clinical Research Coordinator (CRC) Preferred Certifications Licensed Practical Nurse (LPN) Registered Nurse (RN) Skills Excellent verbal communication skills Professional manner and excellent written communication skills, including a familiarity with a variety of writing styles Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.) Well‑developed, analytical and problem solving skills with the ability to understand and interpret clinical data Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution Travel Requirement 0% – 25% Physical, Mental Demands and Working Conditions Position Type: Office‑based Teaches / trains others regularly Frequently travel regularly from the office to various work sites or from site‑to‑site. Rarely works primarily out‑of‑the office selling products/services (sales employees) No physical work site required Lifting: up to 10 pounds – Constantly Lifting: 10 to 25 pounds – Occasionally Lifting: 25 to 50 pounds – Rarely Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum $86,400.00 Pay Range Maximum $138,600.00 EEO Statement 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. 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