Senior Director Coding and Billing Operations

WellBe Senior Medical - Chicago, IL

Full-time - Executive

Chicago, IL

Social Assistance

About the position

We are looking for an individual with deep coding and billing experience with risk adjusted models in value-based care who is looking for an exciting challenge to join WellBe's Operations team to oversee coding and billing services for the organization.

Responsibilities

• Oversee all billing and coding services for the company, including management of third-party vendors, quality assurance and coding education.
• Build strong partnerships with WellBe's cross-functional teams including Clinical Operations, Markets Operations, STARS, Compliance, and leadership to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and accuracy of coding.
• Develop digitally enabled workflows and key performance reporting to ensure process adherence and consistent value delivery.
• Ensure that WellBe's Risk Adjustment programs comply with all applicable guidelines, regulations and laws established by the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), and any other regulations or statutes established at the local, state and federal levels.
• Ensure appropriate codes for each Quality Metric (STARS and HEDIS) is accurate and complies with all applicable guidelines.
• Oversee clinical documentation for accuracy and completeness.
• Manage the claim submission process, complete analysis and immediate action on rejections, and validate submitted codes accepted by the health plan for reimbursement.
• Create a culture focused on Compliance and Core Behaviors.
• Prepare and oversee audits inquiries by government agencies (e.g., CMS, HHS), internal Compliance and other validation audits to ensure efficacy of documentation, coding and quality for WellBe members.
• Develop and implement provider education strategies and tools, monitoring provider performance, developing corrective action plans, direct provider interventions, and assisting physicians and markets that perform below quality benchmark.
• Serve as escalation to providers who require intervention.
• Own program outcomes to ensure complete / accurate assessment and documentation of member profile.
• Execution of HEDIS abstraction.
• Develop improvements for HCC and Quality metric capture in the EHR.
• Track billing and coding production and outcomes while owning results for accuracy and efficiency.
• Develop and provide necessary educational programs and materials for organization and clinicians to include topics of Coding, Clinical Documentation Improvement and ICD10.
• Oversee analysis of both market level and individual clinician performance and provide dashboard of overall performance as well as subsets by disease categories to identify areas for more intensive and focused training.
• Present HCC Coding Materials to physicians effectively and provide oversight and leadership of 1:1 presentations to poor performing clinicians who code outside of clinical support as well as leave HCC gaps.
• Oversee employed clinicians' chart audit, review, and accuracy process.
• Oversee vendors to assure compliance and outcomes.

Requirements

• Bachelor's Degree in Business Administration/Management, or 10 years of relevant experience in lieu of Bachelor's Degree. Master's Degree in Health Administration preferred.
• 12+ years in the Value-Based Healthcare Industry.
• 7+ years management experience in Medical Coding and Clinical Documentation.
• 7+ years in Risk Revenue and HCC Coding.
• 5-7 years in Operational Excellence.
• 3 - 5 years of claims experience as a biller or supervisory capacity.
• AAPC, Certified Professional Coder (CPC).
• AAPC, Certified Risk Adjustment Coder (CRC).
• Current knowledge on all CMS billing/coding regulations.
• Licensure/Certification (CCS-P, CPC, RHIA or RHIT).

Benefits

• Competitive salary
• Health insurance
• Retirement plan
• Paid time off
• Professional development opportunities