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Director, Clinical Operations
3 months ago
JOB SUMMARY: This position is responsible for the vision and strategic execution to drive existing product expansion and enhancements to increase revenue by overseeing all aspects of the clinical operations department's coding team and ensuring the team's successful completion of recurring coding tasks and project work, as applicable. This position will work closely with the VP, Prepay Payment Integrity and clinical physician leadership team to direct the clinical team in identifying inaccurate coding and other health care claim errors, new and existing. This position will oversee and direct a team responsible for using coding and analytic knowledge to review retrospective, concurrent, and prospective claims on behalf of payers. This position will also develop, track and monitor coder productivity, metrics, and team performance and improvement.
JOB ROLES AND RESPONSIBILITIES:
1. Oversee and direct a team of nurses and coders who are:
-Providing support for negotiating desired savings based on product rules and payer guidelines.
-Reviewing submitted medical documentation for bill reviews and adding coding input.
-Contributing to or wholly performing both small- and large-scale coding projects
2. Create, institute and monitor performance metrics for nurses and coders performing claim reviews.
3. Engage with physicians and coding leadership to ensure established workflows between the teams are working as intended.
4. Oversee engagement with the medical review team when required to provide subject matter expertise on the most complex claims for medical review and/or approval on a case-by-case basis ensuring maximum savings.
5. Oversee and collaborate with the analytics team on new and researched coding and editing topics, claim factors, and other applicable reference/source materials to ensure consistency across departments.
6. Engage with leadership of internal "clients", including Operations support staff, Clinical staff, Negotiators, and other staff as applicable.
7. Oversee, and engage with leadership on projects, initiatives, and presentations, including new client account establishment and pilot programs, often acting as a Subject Matter Expert (SME).
8. Set the vision and establish goals/metrics of the clinical coding team supporting all established Corporate KPI's including revenue and savings targets for applicable products.
9. Establish and oversee departmental performance to meet, maintain and monitor metrics within turnaround time limits.
10. Engages with leadership on the hiring, orientation and mentoring of employees.
11. Proactively identifies issues, problems, and opportunities, bringing suggestions, and implementation solutions to leadership to improve efficiency.
12. Establish, implement and oversee both short- and long-term goals, objectives, policies and procedures based on current and future trends. Stay abreast of industry and/or customer changes and communicate as appropriate.
13. Oversee the selection, development, and evaluation of staff to ensure the efficient operation of department.
14. Collaborate, coordinate, and communicate with leadership across disciplines and departments.
15. Ensure compliance with HIPAA regulations and requirements.
16. Demonstrate Company's Core Competencies and values held within.
17. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
18. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE: The incumbent oversees and establishes the vision of a team of clinical coders and nurses as that team works on matters of significant revenue generation and financial importance, using coding guidelines to aid in the profitable resolution of claims on behalf of the Company's Clients, completing routine bill reviews, and participating in audit projects. The incumbent utilizes discretion and judgment to judiciously oversee the team in situations where guidelines may not apply. Also, this job has regular interaction and coordination with leadership and clinical teams to better understand the medical procedures involved, and to explain coding issues. The incumbent is a subject matter expert in coding and a mentor to team members under the incumbent's purview. The incumbent will establish and oversee team performance metrics and track and monitor coding team case review volumes. The incumbent will closely coordinate with leadership and senior physicians and analytics to ensure close coordination between coding team and physician team workflows and processes.
