Manager of Coding and Audit

$80,000 - $95,000/Yr

Clever Care Health Plan - Huntington Beach, CA

Full-time

Hybrid - Huntington Beach, CA

Ambulatory Health Care Services

About the position

Accountable for developing continuous improvement strategies and directing implementation that delivers operational excellence, resulting in high performance in Medicare Risk Adjustment (MRA) and CMS Star programs. Develop, manage, maintain, and support activities and processes related to compliance with local, state, and federal regulatory authorities for HCC coding and audit programs. Manage provider educator team to ensure provider education programs meet established goals pertaining to MRA and quality measures. Provide support to performance improvement initiatives and audits tied to quality and clinical management programs, and member engagement functional areas. Ensure cross-functional collaboration that meets the accurate & appropriate codes submission goal and also improves quality of care delivery, member experience and outcomes.

Responsibilities

• Formulate, direct, implement, administer, supervise, and plan enterprise-wide performance measurement-based strategies relative to Medicare risk adjustment (MRA)
• Drive the definition, measurement, and implementation of MRA improvement activities and projects in support of corporate goals.
• Lead the provider educator team (and vendors) to manage MRA and quality measures education and metrics improvement.
• Create compliance policies and review patient records in accordance with compliance policies and coding guidelines.
• Develop workflows to perform quality assurance (QA) auditing.
• Organize, lead, and participate in coding reviews/audits of medical records for RA reporting of all supported HCC conditions for submission to CMS.
• Responsible for planning, scheduling, and conducting coding audits; and maintaining records of provider or vendor audit results for HCC diagnosis codes.
• Document and present audit findings to the HCC Program team, providers, vendors, and other internal departments in an organized and actionable format.
• Educate and train peers and providers on a one-to-one or group basis to ensure accurate documentation and improve quality of care.
• Collaborate with other areas/departments of the company, external vendors, and medical groups to improve or maintain healthcare quality and risk adjustment metrics and programs.
• Work closely with quality team to develop year-round provider education campaign strategy and parameters.
• Improve core process efficiency, effectiveness, and responsiveness; measure and improve business critical operational KPIs/metrics.
• Maintain up-to-date knowledge and coding credentials, current updates to governmental requirements and plan requirements related to proper coding through continued education, research and reading resource material.
• Positively influence the behavior of others and inspire them.

Requirements

• Bachelor's degree in Healthcare, or related field required or 10+ years HCC coding/auditing and diagnostic coding and education experience.
• Current Coding Certification in one or more of the following: CPC, CPC-H, CPC-P, CCS, CCS-P, CCA, CPMA.
• Valid Driver's License and proof of auto insurance.
• Minimum of five years in MRA and/or HEDIS/Star program management and leadership.
• Experience in education/training HCC risk adjustment coding and documentation.
• Experience in program performance measurement, analytics, reporting and forecasting for MRA/Quality programs and measures.
• Experience in educating/training providers and office staff.

Nice-to-haves

• Health Plan experience preferred.

Benefits

• Equal Employment Opportunity and Affirmative Action workplace.