Director of Risk Management and Revenue Integrity

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 departments 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:

Bachelors 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
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