Job Description

POSITION SUMMARY:

The Risk-Adjustment Manager will act as liaison between IPA/MSO, contracted physicians and other providers (ancillary) and Health Plans. This position maintains the credibility of the Quality Management department by performing medical/clinical chart review and data collection, analysis and coding to capture and obtain data and information related to risk adjustment, STAR/HEDIS and other quality and performance improvement measures and metrics.  Maximize clinical diagnosis codes captured from retrospective and prospective chart review processes, as well as improve coding and data capture of quality/performance measures and initiatives.  Performs medical record reviews at contracted provider practices for completeness, accuracy, compliance with Federal and State laws, regulations and coding guidelines.  Serves as a liaison between organization, medical group and physicians. 

Must be able to communicate/interact effectively and work collaboratively with physicians, other clinical/office staff and other members of the team regarding various projects and initiatives. This position will require physician/provider/staff education on proper documentation and coding of diagnoses codes (ie, HCC, CDPS, Risk-Adjustment) to follow coding guidelines, monitor completion of required member preventive services (ie. STAR, HEDIS, Quality measures), as well as determine physician compliance and improvement. Must be able to generate required reports and protect the confidentiality of all quality management information in accordance with department policies.

The Risk-Adjustment Manager oversees all HCC/CDPS/Risk-Adjustment projects, activities and compliance for all lines of business; participates in reviewing current data collection and reporting processes, identifying and recommending process improvement practices, and making recommendations to the health care team members for implementing timely interventions and provider in-services, with the main objective of increasing the MSO and Client’s Risk Adjustment scores (ie. HCC, CDPS, etc.) and their STAR, HEDIS and other Quality/Performance Improvement rates.

EDUCATION & EXPERIENCE REQUIREMENTS:

 1.      Current and valid AHIMA and/or AAPC Certified Coding Specialist (CCS), Registered Health Information Technology (RHIT) or Certified Professional Coder (CPC) required.  Credentials must be valid and maintained during employment.

2.      Strong knowledge of medical records, medical anatomy and terminology, ICD-10-CM and CPT codes, CMS-HCC model and documentation guidelines, NCQA HEDIS/P4V clinical measures, and State CDPS risk adjustment programs.  Experience with Orange County CalOptima Risk-Adjustment Programs (ie. Medi-Cal CDPS) a plus.

3.      Minimum three (3) years of risk-adjustment/HCC methodology experience and coding, with emphasis in managed care environment within Health Plans or Medical Groups; strong chart audit experience and data abstraction skills with focus on provider education and outreach.

4.      Experience in creating risk-adjustment summary reports and graphs for IPAs and individual physicians based on chart review findings; create coding, documentation and educational materials for physician and staff based on their identified areas for improvement to be used in one-on-one education and outreach.  Monitor for improvement.

5.      Experience in the Managed Care setting with Medicare Advantage, Cal Medi-Connect, Medi-Cal and Covered CA, Commercial Insurance Programs. Familiarity with state and federal laws and professional standards necessary.

6.      Experience working as liaison with physicians, clinical/medical staff, other providers, members, and Health Plans.

7.      Bachelor’s degree or higher, preferred.

SKILLS:

1.      Expertise in medical records review, evaluation, abstraction, coding, data collection and audit procedures related to risk-adjustment (ie. HCC, CDPS, etc), STARS/HEDIS and other quality/performance improvement measures and metrics. Must meet minimum production requirements as indicated.

2.      Strong presentation skills with the ability to perform physician education and group training forums. Share coding and risk-adjustment knowledge and expertise through physician, staff, other providers, members and team education and outreach. Must be able to discuss chart findings and identify deficiencies or areas for improvement. Develop, recommend and/or implement corrective action plans and be able to monitor compliance and improvement trends.

3.      Expertise on coding guidelines (Medicare, Medi-Cal, Commercial), risk-adjustment and sweeps timelines; regulatory agency requirements (ie. CMS), health policy trends, IPA management, and knowledge of NCQA HEDIS requirements. Background knowledge of managed care delivery system.

4.      Advance knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes and pharmacology. Advance knowledge of medical codes involving selections of most accurate and descriptive codes using ICD-9/10-CM, CPT and HCPCS codes, adherence to coding guidelines and compliance standards.

5.      Ability to determine key coding/quality/compliance issues and develop appropriate action plans.

6.      Excellent project and time management skills with the ability to manage and prioritize multiple projects and timelines with minimal supervision. Ensures that projects/initiatives meet deadline requirements. Must be able to work in a fast-paced environment.

7.      Diligence in maintaining accurate tracking/monitoring systems to ensure compliance with contractual and health plan requirements and timelines, as well as follow-up on assigned responsibilities.

8.      Knowledge of computers and software programs such as Microsoft Word, Excel, Access and Power Point.

9.      Strong critical thinking, communication (verbal and written), problem-solving, research, analytical and organizational skills. Must be detail-oriented, follow instructions and able to work independently with minimal supervision and guidance; exceptional initiative and follow-through. Follow HIPAA regulations on highly confidential information. Must have exceptional initiative and follow-though on projects.

10.  Interact professionally with all staff and personnel; team player.

11.  Travel within Orange County and Los Angeles County regions required. Valid driver’s license and reliable vehicle, acceptable driving record, and current auto insurance is required. Travel and work away from the primary office approximately 50-75% of the time.

DUTIES/RESPONSIBILITIES:

1.      Represent the IPA/MSO and act as liaison between contracted physicians and other providers (ancillary) and Health Plans.

2.      Coordinate and perform medical/clinical chart review/audit/abstraction and data collection, analysis and coding to capture and obtain data and information related to risk adjustment, STAR/HEDIS and other quality and performance improvement measures and metrics.

3.      Expertise to find potential coding/quality issues and develop, recommend and/or implement a correction action plan as indicated.  Must be able to monitor compliance and improvement trends.

4.      Conduct physician and staff education and training on proper documentation and coding of risk-adjusted conditions to ensure compliance with established coding guidelines and regulations.

5.      Assist in monitoring physician completion of quality/performance metrics (ie. STAR and HEDIS measures, preventive services, adherence, etc.). Outreach to physicians and staff to ensure compliance and understanding of requirements. Outcomes monitoring.

6.      Develop and implement systematic data collection, monitoring/tracking tools and processes for quality management programs and initiatives. Diligence in updating monitoring/tracking tools as needed.

7.      Accurately interpret collected clinical/medical/technical/statistical data. Prepare and present reports based on results and outcomes.

8.      Oversee complete risk-adjustment process and activities to improve overall outcomes. Assist in the analysis, evaluation, development and implementation of IPA/MSO quality improvement processes and initiatives to increase compliance and scores/rates; completion and implementation of corrective action plans as needed.

9.      Assist and/or coordinates projects and reports with multi-disciplinary teams as needed and as directed by Manager (ie. status reports for Quality Committee oversight reporting).

10.  Use computerized systems to collect, accumulate and assimilate data pertinent to specific quality management projects.

11.  Maintain confidentiality of IPA members and provider information.

12.  Any other duties, responsibilities and projects as assigned.

WORK ENVIRONMENT QUALIFICATIONS:

 This position is required to work on project timelines, and at times may deal with significant time pressures and deadlines. Candidate is expected to use diplomacy and problem-solving skills to procure data and information from various sources, as well as handle incoming public inquiries.

Highly competitive compensation - DOE - Please send your salary requirements along with your resume.