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Risk Adjustment Mgr

OnLok ORCSan Francisco🇺🇸United States

Quick overview

SeniorityMid Senior
Employment typeFull Time
Work modeHybrid
LocationSan Francisco, United States
Microsoft ExcelMicrosoft PowerPointComplianceElectronic Health RecordsICD-10Medical Coding

Job description

JOB PURPOSE
The Risk Adjustment Manager will act as the subject matter expert for risk adjustment and coding. They are responsible to track, report, and collaborate with managers across On Lok PACE to ensure that all risk adjustment activities and workflows are performed in accordance with On Lok PACE business rules, CMS and DHCS rules and regulations, and the decisions of the On Lok PACE risk adjustment and encounter data reporting steering committee.
ROLES AND RESPONSIBILITIES

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Manage all aspects of the risk adjustment program, including developing process workflows, establishing and tracking program performance and ensuring program complies with applicable internal and external governing rules and regulations.

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Analyze claims data to provide analytics within the scope of risk adjustment to the completeness of risk adjustment data and to implement Risk Adjustment training and programs.

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Correct and reduce data submission errors.

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Supervise Risk Adjustment Analysts to provide thorough monitoring, report findings of chart audits, and opportunities to communicate improved documentation and coding practices back to providers and staff.

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Support ongoing retrospective and prospective audit system to assure improved documentation and coding occurs in a timely manner.

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Collaborate with cross-functional departments (Health Plan Services, Business Intelligence, Regulatory Affairs, and Compliance, and Quality Assurance) to ensure transparency and continuity of policy enforcement for all risk adjustment procedures.

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Assist with the documentation of coding-related departmental policies and procedures, both general and specific to all risk-adjusted lines of business.

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Serve  as risk adjustment coding subject matter expert for Medicare, Medi-Cal, and health plans, both in day-to-day operations, the On Lok PACE risk   adjustment, and encounter data reporting steering committee.

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Remain cognizant of current and emerging regulatory changes as it relates to Risk Adjustment, Coding, and RADV audits.

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Evaluate and oversee the development and implementation of CMS and DHCS risk adjustment program changes; incorporate changes and requirements into policies and strategies.

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Evaluates and manages risk adjustment vendors; acts as project manager for risk adjustment related projects/implementations.

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Use analytics to define risk adjustment focus areas. Identify areas to increase quality and maximize opportunities.

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Develop performance targets metrics for both internal and external constituents. Track progress against stated goals and drive to attainment.

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Develop and distribute provider reports for the steering committee as it relates to risk adjustment metrics and performance.

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Hires, trains, coaches and evaluates the performance of direct reports.

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Collaborates with CMO and Medical Directors to review risk adjustment focus areas and opportunities for improved documentation and coding.
REQUIRED QUALIFICATIONS
Education
Education LevelEducation Details
Bachelor's Degreein business, health administration, health policy, finance or a related field is required.
Work Experience
ExperienceExperience Details
4-7 yearsMinimum of 5 years of experience in Medicare risk adjustment.
4-7 yearsA minimum of 5 years of medical coding experience.
4-7 yearsBoth Medicare and Medi-Cal experience.
Knowledge, Skills and Abilities
KSAs

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Coding Certificate required: either CPC or CRC from AAPC or CCS from AHIMA.

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Extensive knowledge of ICD-10-CM coding guidelines.

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Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.

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Excellent organizational, project, and program management skills; experience leading change and implementing programs.

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Strong quantitative and analytical skills with the ability to communicate data concisely and clearly to a variety of audiences.

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Demonstrated familiarity with the utilization of electronic health records systems and their applications.

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Ability to manage significant workload and work efficiently with minimal supervision.

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Proficient in Excel, Word, and PowerPoint programs.

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Demonstrated ability to be an effective, collaborative partner with internal and external stakeholders.

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Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels within the organization.

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Experience working across sectors, in a fast-growth, fast-paced environment, and/or in a highly complex, matrixed organization.
PREFERRED QUALIFICATIONS
Education (Preferred)
Education LevelEducation Details

And/Or

Master's Degreein related field.
Knowledge, Skills and Abilities (Preferred)
KSAs

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CRC is strongly preferred.

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