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Manages all aspects of the RA (Risk Adjustment) Auditing and provider education including planning, organizing, directing and monitoring for both internal and external entities. Oversight of the Risk Adjustment Data Validation (RADV) process to ensure that the CMS objectives are met. Responsible for the daily operations, planning, organizing, staffing, directing and controlling all functions of auditing and provider education.
Manages initiatives through indepth knowledge of RAPS and strong organizational partnerships.
Drives strategic planning through market relationship management.
Manages, strategizes and communicates all Risk Adjustment coding processes to Senior Leadership for any process improvements and vendor coding oversight.
Directs all provider education supplied to internal and/or external entities using analytical data to determine which providers are targeted.
Develops effective training processes for the auditors and provider educators in collaboration with the senior leadership team.
Oversee and conduct audit and quality reviews and develops process improvements based on the gaps.
Subject Matter Expert (SME) for proper risk adjustment coding, CMS data validation and serves on the RADV committee as the main point of contact.
Manages all departmental activities in relation to CMS RADV and HHS office of Inspector General (OIG) for coding compliance.
Responsible for strategizing and directing activities and planning team resources accordingly to complete additional risk adjustment audit requests (i.e. outside auditors' requests);
Works with cross functional areas to develop and employ best practices for provider education and issue resolution;
Conducts performance evaluations, conducts mentoring activities and provides continuous coaching;
Performs other duties as assigned.
Required A Bachelor's Degree in a related field or equivalent work experience
Required 5 years of experience in professional coding either in a hospital or physician setting
Required 3 years of experience in risk adjustment coding/auditing
Required 3 years of management experience
Intermediate Demonstrated written communication skills
Intermediate Demonstrated interpersonal/verbal communication skills
Advanced Demonstrated organizational skills
Intermediate Ability to lead/manage others
Intermediate Ability to work as part of a team
Intermediate Ability to work independently
Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Licenses and Certifications: A license in one of the following is required:
Required Certified Professional Coder (CPC) CPC required
Preferred Certified Professional Medical Auditor (CPMA)
Required Intermediate Other Knowledge of RAPS and HEDIS
Required Intermediate Microsoft Excel Knowledge in Microsoft Office including Outlook, Word, Excel, Visio, and Power Point