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Director of Risk Management and Revenue Integrity

11 hours ago

Franklin, Tennessee, United States American Health Plans Full time

JOB SUMMARY:

Responsible for managing the Medicare Advantage risk adjustment process and encounter data processing (EDPS) in accordance with CMS regulations. The Director of Risk Management is responsible for the timely and accurate collection, flow and processing of data for risk adjustment activities. This role will establish, monitor, and maintain the processes and systems that collect and process the data from claims, encounters, electronic medical records, medical record coding, and other supplemental data sources. This role acts as the risk adjustment program subject matter expert and works closely with other areas of health plan operations and programs, ensuring risk adjustment data operations are administered accurately, timely and in compliance with CMS regulations.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

  • Manage the Electronic Data Processing (EDPS) data submission process and ensure that all available data is accepted by CMS and manage the transition from RAPS to EDPS

  • Collaborates with coding staff & vendors to develop relevant coding guidance to the provider population consistent with established coding authorities and in compliance with relevant federal guidance

  • Establish and maintain HCC visit review program to ensure proper documentation of diagnoses, and validation of diagnoses with feedback to Providers

  • Responsible for responding to and overseeing CMS Risk Adjustment Data Validation (RADV), and OIG audit requests

  • Develop and update department's policies and procedures according to established workflows

  • Assist with the development, implementation, and oversight of auditing projects

  • Facilitate appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk through extensive interaction with providers, care management and nursing staff, other care givers and the coding staff

  • Review data and trends to identify additional areas of opportunity and to close gaps identified via data generated by Analytics

  • Deliver provider-specific metrics on Gap-closing opportunities as needed

  • Maintain knowledge of coding rules and program regulations to ensure the documentation in the patient record accurately reflects all elements impacting the patient risk score thereby contributing to a compliant patient record

  • Maintain vendor contracts and relationships as needed

  • Oversee vendor software users

  • Monitor vendor progress and performance and works to improve vendor performance if needed

  • Assist with developing coding policies and long-term plan to use technology and other resources to provide more and better information to network providers

  • Coordinate and develop metrics related to risk adjustment operations to inform leadership on progress of activities and risk adjustment programs

  • Maintain knowledge of applicable current and proposed laws, regulations, and sub-regulatory guidance (e. g., CMS) applicable to Risk Adjustment specifically and general knowledge of Medicare Advantage requirements to ensure that risk adjustment program is in compliance with government regulation

  • Draft and maintain policies and procedures, standard operating procedures, and work instructions

  • Develop resolution and plan for action for identified raps and EDPS discrepancies

  • Responsible for assisting leadership with implementation and oversight of risk adjustment and mechanism for projects

  • Other duties as assigned

JOB REQUIREMENTS:

  • Excellent analytical and problem-solving skills

  • Ability to communicate to both internal and external clients on new developments

  • Enjoy engaging in the outlining of program development and management processes, manages the overall scoping, planning, business requirements gathering and delivery of risk adjustment program activities from idea inception to ongoing support and enhancement

  • Communicate with internal and external stakeholders - progress reporting and vendor management

  • Successful completion of required training

  • Handle multiple priorities effectively

QUALIFICATIONS:

  • Bachelor's degree (or higher/equivalent)

  • Credentials preferred in any of the following: RHIA, RHIT, CCS and/or CPC, CRC, CCDS/CCDS-O, CDIP

  • Experience with risk adjustment data validations or equivalent compliance audits

  • Knowledge of RAPS, 837I and 837P EDPS formats and file protocols

  • Knowledge of CPT, ICD-9, ICD-10, HEDIS, Medicare services and reimbursement methodologies, RBRVS

  • Extensive knowledge of Medicare and CMS Risk Adjustment payment rules, regulations and guidelines as it relates to managed care organizations required

  • Ability to lead projects, initiatives, or teams as needed to achieve accurate & complete documentation for the health plan & health system clients

  • Relevant Coding/Auditing Experience, especially with some leadership experience in the area

  • Proven track record of managing partners / vendors

  • Background in analytics, statistics, data management

  • Ability to present effectively to clients & providers; strong ability to influence

  • A passion for results & a strong sense of ownership of the results

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.