Director of Coding and Risk Adjustment

Profile

Description

The Director, Coding and Risk Adjustment ensures coding is accurate and properly supported by clinical documentation within the health record. Follows state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records. Will be responsible for managing a large team of certified coders. May participate in provider education programs on coding compliance. Will be responsible for ensuring defined strategies and programs are implemented within the coding team, coordinate large scale projects, support technical/operational procedures and processes, drives outlined goals and objectives, and track performance. Provides input into functions strategy.

Responsibilities

Accountabilities


Lead regional teams of coders responsible for all risk adjustment functions to support PCOs risk adjustment optimization
Participates in the development, implementation and refinement of prospective and retrospective diagnosis coding programs and provider support
Lead team of on-shore/off-shore coders to support multiple lines of business.
Develop and monitor KPI's to track productivity and coder performance.
Monitor and analyze the effectiveness of risk adjustment programs, processes, infrastructure, reporting, and work collaboratively with strategy team on potential changes.
Participates in the development, implementation and refinement of new programs or modifications to existing coding processes
Participates in the development and implementation of infrastructure (processes, systems, talent) to support an effective risk adjustment program as CMS evolves the model and guidance
Ensures coding team collaboration with the Auditing and Education team to ensure monitoring and training of coding accuracy and clinical documentation to ensure internal control consistent with CMS and State requirements to support RADV or other regulatory
Ensures coding team collaboration with internal departments and vendors to ensure complete and timely submission of claims/encounters to the health plan
Collaborates with internal departments as appropriate to develop and execute of strategies, programs and plans to engage the physicians in proper assessment, diagnosis coding and documentation of all patients
Utilizes analysis to identify trends and opportunities for improvement and further development of programs, processes and workflow impacting risk adjustment
Remains current and informed about CMS and industry trends and best practices, utilizing this knowledge to refine and advance the risk adjustment program
Deep understanding of coding guidelines to support fee-for-service and ACO business.


Required Qualifications


Knowledge of CMS Risk Adjustment rules and regulations for Medicare Advantage
10 or more years of technical experience
8 or more years of management experience
CCS or CPC Certification
Experience leading a large collaborative team to include overseeing offshore resources
Understanding of medical terminology such a s diagnosis codes (ICD-10), and other claims coding topics such CPT and HCPCS and related Hierarchical Conditions (HCC) methodologies


Preferred Qualifications


HEDIS/Stars experience
Master's degree
Primary Care Based Experience


Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

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