at Health Care Service Corporation in Chicago, Illinois, United States
Job Description
At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.
Come join us and be part of a purpose driven company who is invested in your future!
Job Summary
This position is responsible for the overall management and implementation of various initiatives including, but not limited to, Risk Adjustment Programs, Accountable responsibilities include the overall development, refinement, maintenance, monitoring and oversight of Medicare, Medicaid and Retail/Small Group risk adjustment initiatives and operations. The position is responsible for all aspects of decision-making and implementation of medical record coding reviews and coding policies to maximize revenue for the organization Leads a cross-functional, multi-departmental team in identifying improvement opportunities for clinical provider training, medical record documentation, data gathering, suspect identification, and health plan reporting to ensure accuracy and compliance with CMS models and guidelines. This position will work closely with the Stars and Encounters Leaders to ensure integration and delivery of these strategies.
1. Accountable for the overall integration, management and implementation of the Medicare Risk Adjustment Program across HCSC (i.e. network management, customer service, clinical services, information technology, and finance departments).
2. Ensure development, implementation, and maintenance of policies and procedures to support all operations processes & procedures and monitoring adherence.
3. Directs, oversees and completes all aspects of Risk Adjustment Projects and Initiatives.
4. Develop, train and mentor staff members.
5. Develop and implements chart pull strategy and analysis for chart review including vendor identification and selection.
6. Oversee the following day-to-day risk adjustment related operational activities:
* Operations of all RN and coder team reviewers, including decision support on coding issues.
* Coding processes and procedures, ensuring that the diagnosis supports the medical necessity of the procedure.
* Tracks and monitors all physicians' sign-offs after completion of review.
* Participates in CMS user group calls and regional meetings.
* Ensures that recorded forms are complete, accurate and in accordance with policy and procedures.
* Analyzes data collection for patterns and trends to identify opportunities to improve documentation.
7. Develop, implements, and/or maintains documentation consistent with CMS regulations, company goals and policies.
8. Coordinate and completes CMS Risk Adjustment projects.
9. Monitor and summarizes progress of CMS Risk Adjustment projects and initiatives. Identifies and evaluates potential new programs and services to determine cost effectiveness and revenue potential.
10. Identify opportunities; provides guidance and suggestions for quality performance improvements in the collection and recording of clinical documentation.
11. Manage vendor relationships.
12. Manage annual CMS audit/data validation and RADV audit Risk Mitigation strategic initiatives.
13. Work with Data, Claims, Network, Provider Relations, Compliance and Legal areas to achieve objectives.
14. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
15. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
16. Maintain complete confidentiality of company business.
17. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
Required Job Qualifications:
* Bachelor's Degree
* 10 years of experience in health care, managed care, health insurance or strategic consulting
* 6 years' leadership / management experience; 4 years' experience in medical record review, case management, utilization management, managed care, Home Health, QA Review, HEDIS review; 4 years' experience with healthcare payment and coding methodologies (i.e. ICD-9, CPT, DRG and HCC coding).
* Experience with managed care data systems and reports.
* Experience with Medicare, Medicaid and... For full info follow application link.
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
