Supervisor Strategic Risk Adjustment and Quality

Job Title

This job is responsible for developing plans and managing activities in support of Risk Adjustment and Quality/HEDIS.

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

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

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)

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

Physical, Mental Demands and Working Conditions

Position Type: Remote

Teaches / trains others regularly: Frequently

Travel regularly from the office to various work sites or from site-to-site: Frequently

Lifting: up to 10 pounds: Constantly

Lifting: 10 to 25 pounds: Occasionally

Pay Range

Pay Range Minimum: $86,400.00

Pay Range Maximum: $138,600.00