Davita Inc.
Director, Government Programs Risk Adjustment & Audit
Davita Inc., Kansas City, Missouri, United States, 64101
Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:
Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute Annual incentive bonus plan based on company achievement of goals Time away from work including paid holidays, paid time off and volunteer time off Professional development courses, mentorship opportunities, and tuition reimbursement program Paid parental leave and adoption leave with adoption financial assistance Employee discount program Job Description Summary:
The Director, Government Programs Risk Adjustment & Audit assumes overall leadership of the risk adjusted revenue optimization strategy and oversight of Government Programs Risk Adjustment programs. Job Description
Interface
with
Blue KC
operational and clinical leadership to
assist
in identification of operational and
coding
best practices in
chronic condition management
, understanding clinical suspects and monitoring of
appropriate clinical
documentation and quality coding
.
Interface with
external provider partners
'
operational and clinical leadership to
assist
in identification of operational and
coding
best practices in chronic condition management, understanding clinical suspects and monitoring of
appropriate clinical
documentation and quality coding
.
Provide
Government Programs oversight to ensure
Medicare Advantage and ACA
Risk Adjustment and state regulations are
maintained
.
Own
the
coordination and implementation of
retrospective
medical record retrieval and review campaigns, prospective provider education
programs
,
regulatory audit activities, and
compliance monitoring initiatives
designed to ensure
accuracy and compliance
of
reported conditions.
Manage the team accountable for risk adjusted revenue initiatives and works cross-functionally with clinical and technical teams to develop the tools, processes, and reporting
required
to ensure
a
complian
t risk adjustment program
.
Build
and
maintain
the risk adjustment roadmap
which
defines the
strategic initiatives
, operational timelines
and
regulatory audit
and oversight
functions
to meet risk adjustment regulatory requirements
and drive
program performance
.
I
nterpret and
monitor
state and federal regulatory guidance for
risk adjustment,
audit and documentation and coding accuracy standards.
Provide oversight of
the
documentation and coding educational programs
with performance tracking for internal coding operations and provider partners based on analytics and guidance
for Risk Adjustment initiatives.
Develop and deliver educational materials
or programs
for
accurate
documentation to support all Government Programs
quality care gap closure.
Oversee the
formal (Interrater Reliability and Risk Adjustment Data Validation) and internal audit
activities
of coding/diagnosis data collected from professional and facility medical records to ensure proper coding and compliance with risk adjustment requirements
Monitor
risk adjustment vendor
s to
ensure
performance standards
are
met.
Develop and
maintain
prospective
programs
to support ongoing assessment of chronic conditions
Chair the Risk Adjustment Workgroup
t
hat
partner
s
with multiple stakeholders and business unit leadership
to drive ongoing process improvement
to
ensure
risk adjusted revenue optimization.
Develop and manage budget; control expenses while meeting operational,
financial
and service requirements.
Maintain expert knowledge of ACA risk adjustment regulation
s
Maintain expert knowledge of Medicare Advantage risk adjustment regulations to support
runout and future CMS audits.
Ensures programs are
established
to
support Blue Association
host plan
requests such as medical recor
d
retrieval
and
delivery of care gaps
or
conditions to
the provider-facing
Blue
KC tea
m and Association provider education requirements are
maintained
.
Minimum Qualifications Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, Information Systems, Business Administration or other relevant clinical academic field; or an equivalent combination of education and experience 5+
years
of clinic or hospital experience and/or managed care experience. 5+ years' experience in Risk Adjustment and HEDIS / Stars coding 3+ years' team lead or project lead experience Certified Risk Adjustment Coder AND/OR Certified Professional Coder with the American Academy of Professional Coders with the requirement to have one and obtain both certifications, CRC and CPC. Advanced knowledge of ICD10-CM coding. Proficiency
in MS Office (Excel,
PowerPoint
and Word). Must be able to work effectively with common office software, coding software, EMR and abstracting systems. Ability to travel locally up to 75%. Strong organizational skills, ability to prioritize responsibilities with attention to detail. Must be self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, strong follow-through skills and a solutions-oriented attitude. Innovative thinker with ability to articulate a vision, manage complexity, and lead
change amongst internal and external stakeholders;
Demonstrated
experience in successful change management strategies. Ability to Develop Long Term Relationships Excellent Oral & Written Communication Skills Good Work Ethic, Desire to Succeed, Self-Starter Strong business acumen and analytical skills Ability to deliver training materials designed to improve provider compliance Ability to use independent judgment, and to manage and impart confidential information Preferred Qualifications Master's degree in Business
, Healthcare Administration or related field. Licensed RN (preferred) 3+ years nursing experience (Note: license must be current in Missouri & Kansas) Experience with a variety of EMR systems strongly preferred Ability to read and interpret medical records, including handwritten records Conscientious problem solver, willing to learn, takes personal pride in their work performance/accuracy Excellent verbal communication skills - clear,
concise
and appropriate 10 years of broad health care experience,
to include
health plan experience, provider payment, innovative payment design and data analysis. Previous
development of clinical documentation improvement programs Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.
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Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute Annual incentive bonus plan based on company achievement of goals Time away from work including paid holidays, paid time off and volunteer time off Professional development courses, mentorship opportunities, and tuition reimbursement program Paid parental leave and adoption leave with adoption financial assistance Employee discount program Job Description Summary:
The Director, Government Programs Risk Adjustment & Audit assumes overall leadership of the risk adjusted revenue optimization strategy and oversight of Government Programs Risk Adjustment programs. Job Description
Interface
with
Blue KC
operational and clinical leadership to
assist
in identification of operational and
coding
best practices in
chronic condition management
, understanding clinical suspects and monitoring of
appropriate clinical
documentation and quality coding
.
Interface with
external provider partners
'
operational and clinical leadership to
assist
in identification of operational and
coding
best practices in chronic condition management, understanding clinical suspects and monitoring of
appropriate clinical
documentation and quality coding
.
Provide
Government Programs oversight to ensure
Medicare Advantage and ACA
Risk Adjustment and state regulations are
maintained
.
Own
the
coordination and implementation of
retrospective
medical record retrieval and review campaigns, prospective provider education
programs
,
regulatory audit activities, and
compliance monitoring initiatives
designed to ensure
accuracy and compliance
of
reported conditions.
Manage the team accountable for risk adjusted revenue initiatives and works cross-functionally with clinical and technical teams to develop the tools, processes, and reporting
required
to ensure
a
complian
t risk adjustment program
.
Build
and
maintain
the risk adjustment roadmap
which
defines the
strategic initiatives
, operational timelines
and
regulatory audit
and oversight
functions
to meet risk adjustment regulatory requirements
and drive
program performance
.
I
nterpret and
monitor
state and federal regulatory guidance for
risk adjustment,
audit and documentation and coding accuracy standards.
Provide oversight of
the
documentation and coding educational programs
with performance tracking for internal coding operations and provider partners based on analytics and guidance
for Risk Adjustment initiatives.
Develop and deliver educational materials
or programs
for
accurate
documentation to support all Government Programs
quality care gap closure.
Oversee the
formal (Interrater Reliability and Risk Adjustment Data Validation) and internal audit
activities
of coding/diagnosis data collected from professional and facility medical records to ensure proper coding and compliance with risk adjustment requirements
Monitor
risk adjustment vendor
s to
ensure
performance standards
are
met.
Develop and
maintain
prospective
programs
to support ongoing assessment of chronic conditions
Chair the Risk Adjustment Workgroup
t
hat
partner
s
with multiple stakeholders and business unit leadership
to drive ongoing process improvement
to
ensure
risk adjusted revenue optimization.
Develop and manage budget; control expenses while meeting operational,
financial
and service requirements.
Maintain expert knowledge of ACA risk adjustment regulation
s
Maintain expert knowledge of Medicare Advantage risk adjustment regulations to support
runout and future CMS audits.
Ensures programs are
established
to
support Blue Association
host plan
requests such as medical recor
d
retrieval
and
delivery of care gaps
or
conditions to
the provider-facing
Blue
KC tea
m and Association provider education requirements are
maintained
.
Minimum Qualifications Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, Information Systems, Business Administration or other relevant clinical academic field; or an equivalent combination of education and experience 5+
years
of clinic or hospital experience and/or managed care experience. 5+ years' experience in Risk Adjustment and HEDIS / Stars coding 3+ years' team lead or project lead experience Certified Risk Adjustment Coder AND/OR Certified Professional Coder with the American Academy of Professional Coders with the requirement to have one and obtain both certifications, CRC and CPC. Advanced knowledge of ICD10-CM coding. Proficiency
in MS Office (Excel,
PowerPoint
and Word). Must be able to work effectively with common office software, coding software, EMR and abstracting systems. Ability to travel locally up to 75%. Strong organizational skills, ability to prioritize responsibilities with attention to detail. Must be self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, strong follow-through skills and a solutions-oriented attitude. Innovative thinker with ability to articulate a vision, manage complexity, and lead
change amongst internal and external stakeholders;
Demonstrated
experience in successful change management strategies. Ability to Develop Long Term Relationships Excellent Oral & Written Communication Skills Good Work Ethic, Desire to Succeed, Self-Starter Strong business acumen and analytical skills Ability to deliver training materials designed to improve provider compliance Ability to use independent judgment, and to manage and impart confidential information Preferred Qualifications Master's degree in Business
, Healthcare Administration or related field. Licensed RN (preferred) 3+ years nursing experience (Note: license must be current in Missouri & Kansas) Experience with a variety of EMR systems strongly preferred Ability to read and interpret medical records, including handwritten records Conscientious problem solver, willing to learn, takes personal pride in their work performance/accuracy Excellent verbal communication skills - clear,
concise
and appropriate 10 years of broad health care experience,
to include
health plan experience, provider payment, innovative payment design and data analysis. Previous
development of clinical documentation improvement programs Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.
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