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Sr Manager Risk Adjustment Medical Coding

1 month ago

Jacksonville, United States Florida Blue Full time

**Sr Manager Risk Adjustment Medical Coding**

Finance Full-time 26560

* Remote, United States

* Jacksonville, Florida, United States

* United States

* Remote, United States

* Jacksonville, Florida, United States

* United States

* Remote, United States

* Jacksonville, Florida, United States

* United States

* Remote, United States

* Jacksonville, Florida, United States

* United States

* Remote, United States

* Jacksonville, Florida, United States

* United States

The Sr Manager Risk Adjustment Audit, is responsible for providing leadership and coaching to the Audit team to ensure compliance with the Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) risk adjustment data submission activities that support accurate medical record documentation, claim, pharmacy, and enrollment data transmission. The Audit Team will support risk adjustment audit oversight . This position is also accountable for coordinating and leading vendor performance and quality audits. The Sr. Manager will oversee reporting and corrective action plans related to risk adjustment audit findings in support of education and coding accuracy . This Sr. Manager will leverage their breadth of coding knowledge, medical claims and coding audit expertise, and experience within a provider practice to manage staff and lead strategic initiatives with value-based provider groups, leaders, and key stakeholders. Tracks status and results of audit projects and interfaces with analytics and other operational departments to report findings and key opportunities for provider improvement and education. Facilitates the review and rebuttal process. For vendors, this includes adhering to client SLA requirements and ensuring auditors are applying coding rules appropriately. Program framework will also include a reporting portfolio and an associated continuous improvement workflow. * Oversees Audit Operations

* Lead the Audit team by coaching, motivating and developing resources to enable cultural change, meet operational business goals and become a high performing organization.

* Leads development and documentation of standard operating processes and procedures for provider and vendor quality audit reviews (based on industry standards).

* Manages inventory and team assignments to maximize productivity and meet department objectives and timelines.

* Oversees the development, documentation, implementation, and maintenance of a formalized appeal/rebuttal program .

* Performs ongoing quality assurance (QA) audits of internal audit team.

* Ensures that staff are properly trained on policies, procedures and best practices and that certifications are maintained as required.

* P rovide routine feedback to staff, including corrective action where appropriate.

* Communicate s and problem solve s with leadership on specific coding issues and/or training needs. Leads ongoing feedback process to ensure outcome trends are effectively communicated to the audit team for continuous performance improvement.

* Confers with management to identify training needs based on data and other factors that will make an impact to overall department goals.

* Utilizes an understanding of the CMS and HHS regulations and reimbursement methodologies to execute audit procedures, perform detailed analyses, reach sound conclusions and document results for risk adjustment

* Serves as a coding subject matter expert (SME ) in all areas of coding to include CPT, HCPCS, ICD-10, Coding Clinic.

* K eeps actively informed on the business climate of the healthcare industry (e.g., CMS Hierarchical Condition Categories and ACA).

* Serves as a resource for department managers, staff, physicians, and administration to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines, and regulatory requirements.

* Provides input on development of appropriate training material s for provider educators to use with providers.

* Evaluate s opportunities for automating and streamlining processes and gain agreement to implement improvements throughout the department.

* Build s strong working relationships that cross business sector and organization boundaries to ensure business objectives are met and issues resolved.

* Build s strong working relationship s with outsourced services (e.g. vendors, providers and partners) to ensure processes meet business requirements and issues are resolved, including routine engagement with vendors .

* Gain agreement and alignment of business initiative vision and goals with leaders inside and outside of the business unit.

* Engage in strategicbusiness planning and tactical implementation activitiesinitiatives .

* Ensure continuous improvement, creativity and innovation is embedded in the culture of Audit department

* Coach team members on processes for identifying root causes for improvement opportunities and developing improvement action plans.

* Determine, gain agreement and implement improvements based upon trends and issues impacting the accuracy of CMS and HHS submission data.

* Evaluate opportunities for automating and streamlining processes and gain agreement to implement improvements throughout the department

* Create an environment that encourages new ideas, designs and approaches to situations and problems.

* Monitor, evaluate and provide feedback on new processes, designs, etc. to enable additional improvements.

* 6+ years related work experience or equivalent combination of transferable experience and education.

* 3+ years direct supervisory/management experience

* Related Bachelors degree or additional related equivalent work experience

* An active coding credential or designation (COC, CPC, CPMA, CRC, CCS or CCM) from the American Association of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) Upon Hire

* Certified Risk Adjustment Coder (CRC) designation 1 Year

* Experience in healthcare/managed care operations, Medicare and HHS risk adjustment.

* Knowledge of and ability to coach management team on the following service tools, processes and programs:

* CMS and HHS regulatory requirements and reimbursement methodologies

* Internet research capabilities and tools

* Data research and analysis processes

* Demonstrated experience in coding, chart review, and data validation.

* Knowledge of finance principles and budget planning to conduct input for operational planning, control and budgets and for the development of operational strategies, objectives and goals

* Knowledge of CMS and HHS financial guidelines and reporting requirements

* Writing skills (composes complex written arguments that influence outcomes)

* Presentation skills (presenting complex and technical information to audiences with diverse knowledge base)

* Knowledge of continuous improvement principles and tools, Six-sigma preferred

* Masters degree

* PMP - Project Management Professional

* Demonstrated Florida Blue product knowledge, knowledge of over Medicare Advantage and Commercial ACA products

* Demonstrated understanding of reform and CMS compliance standards

* Demonstrated knowledge of Centers for Medicare and Medicaid Services (CMS), Reimbursement and Risk Adjustment methodology

* Minimum 3 years experience in provider practice setting or a managed care organization.

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