Under the direction of the Director of Professional Coding, the Manager, Risk Adjustment Coding and Quality Assurance Program is responsible for responding to and overseeing CMS Risk Adjustment Data Validation (RADV) audit requests as well as education and training of coders, clinicians and providers. The Manager demonstrates strong leadership, operational planning and presentational skills as well as display good judgment and critical thinking to address business problems that touch upon the coding unit's work, to ensure successful integration of initiatives and clean claims.
The essential functions listed are typical examples of work performed by positions in this job classification, and are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Specific duties and responsibilities may vary depending on department or program needs without changing the general nature and scope of the job or level of responsibility. Employees may also perform other duties as assigned.
• Employees must abide by all Joint Commission requirements including, but not limited to, sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
• Employees must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions.
CONNECT with people by calling them their proper name, or the name they prefer (Mr., Mrs., Dr.)
INTRODUCE yourself and your role.
COMMUNICATE what you are going to do, how long it will take, and how it will impact the patient.
ASK permission before entering a room, examining a patient, or undertaking an activity.
RESPOND to patient's questions or requests promptly; anticipate patient needs.
EXIT courteously with an explanation of what will come next.
1) Management of Auditing and Coding Review
a. Directs and assumes accountability for operational and fiscal performance of the end-to-end process serving our Medicare Advantage patient population. [Currently this includes approximately 1200 patients enrolled in the Stanford Health Care Advantage Platinum (HMO) and the Stanford Health Care Advantage Gold (HMO).]
b. Works with Digital Solutions to develop coding and documentation tools, templates and system edits to manage HCC workflows.
c. Oversees and manages the volume (inventory) and schedule of provider and vendor medical record audits for complete and accurate documentation and code capture.
d. Directly performs audits and/or oversees balancing of workloads among coders, allocates work to ensure timely and accurate completion of audits. Documents and tracks results and provides timely feedback to coders.
e. Uses audit findings identify trends and patterns, makes recommendations for additional focused audits, follow up actions and/or provider education and training.
f. Refines internal workflows, tools and training to support high productivity, quality and efficiencies.
g. Interprets and summarizes coding guidelines and CMS regulations and incorporate changes to guidelines and regulations into audit practice.
h. Oversees updates to the Professional Coding Department's Risk Adjustment and Quality Assurance coding policies and procedures, collaborates with outside vendors and consultants and reports out the results of the QA projects to management and presents team progress to senior leaders.
2) Provider and Staff Education
a. Supports and delivers education/ training of the Stanford Health Care Advantage Platinum (HMO) and the Stanford Health Care Advantage Gold (HMO) to providers to assist them in their understanding of appropriate and compliant coding and documentation. Training will be conducted face-to-face, and you will be required to travel to provider's locations.
b. Serves as a resource and educator to both internal (clinicians and coders) and external stakeholders regarding HCC coding and documentation.
c. Reviews provider training tools and presentation materials for accuracy in terms of coding and documentation language and the most current CMS requirements.
d. Reviews systems, business processes and controls to optimize risk score accuracy and provide consultation on ways to improve where applicable.
3) Managing Team Performance
a. Develops and utilizes tools and reports to track and monitor coder productivity and quality. Track, trend and report individual coder productivity, performance and quality results weekly.
b. Monitors and routinely samples the quality of work done by each coder ensuring adherence to CMS and ICD10 coding guidelines. Provides regular feedback to each coder for all work reviewed.
c. Identifies and addresses staff performance issues or gaps on a timely basis. Takes action as needed according to company policies.
d. Develops and refines tools, training and reference materials to support and ensure consistency across coders.
4) Development and Knowledge Sharing
a. Stays informed about CMS and industry trends and best practices; utilizes this knowledge to recommend modifications to SHC's risk adjustment programs.
b. Serves as a subject matter expert and lead coding resource to the Risk Adjustment Coding and Quality Assurance area.
c. Maintains a current and strong understanding of generally accepted coding standards and CMS Risk Adjustment guidelines
d. Provides subject matter expertise for provider training programs.
e. Works with leadership to identify new opportunities or assess the merits of coding initiatives that may be performed in house (e.g., simulated RADV, chart review etc.).
5) Talent Management
a. Hires, trains and coaches certified coders with expertise in Risk Adjustment coding.
b. Oversees education, training and tools to the coding team/provider trainers to support high accuracy rates and develop skills so that staff may function independently.
c. Supports staff development assigning tasks to enhance their learning and build confidence.
d. Develops and supports a positive, collaborative working environment.
All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status or on the basis of disability.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: Bachelor's degree in a work-related field/discipline from an accredited college or university is desired.
Experience: Minimum 5 years in medical claims coding required; a progressively responsible role with leadership experience and previous experience working in an educational / training role preferred. Experience working with CMS, risk adjustment, health insurers and medical providers strongly desired.
License/Certifications: One of the following certifications from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) is required: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Risk Coder (CRC), and/or Certified Documentation Improvement Specialist (CDIS). Desirable - American Academy of Professional Coders (AAPC): Certified Risk Coder (CRC), and/or Certified Documentation Improvement Specialist. (CDIS).
Knowledge, Skills and Abilities:
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
Ability to apply judgment and make informed decisions.
Ability to communicate complex concepts in simple form to cross-functional departments or teams.
Ability to conduct analysis and formulate conclusions.
Ability to foster effective working relationships and build consensus.
Ability to plan, organize, prioritize, work independently and meet deadlines.
Knowledge of and ability to research laws, regulations and billing rules, including CMS manuals.
Knowledge of computer systems and software used in functional area.
Knowledge of local, state and federal regulatory requirements related to areas of functional responsibility.
Knowledge of Medical Terminology.
Knowledge of new technologies (in specific field) and maintain and stay abreast of updates and changes.