Senior Risk Adjustment Coder – Government Programs
Capital Blue Cross
Manager, Risk Adjustment Coding
Capital Blue Cross
full-time
Posted on:
Origin: • 🇺🇸 United States • Pennsylvania
Visit company websiteSalary
💰 $83,800 - $157,890 per year
Job Level
SeniorLead
About the role
- Develop, manage, and execute Capital’s Risk Adjustment Program Coding and Chart Retrieval operations strategy and initiatives
- Provide strategic and tactical direction in collaboration with the Stars & Risk Adjustment Sr. Director and Medical Director
- Function as a Risk Adjustment subject matter expert and perform analysis and market research
- Manage work plans, cross-functional team collaboration, and implementation of standards, controls, tactics, initiatives, and systems
- Lead coding and chart retrieval teams to ensure required accuracy and efficiency through quality assurance processes and controls
- Lead risk mitigation and HCC compliance audits and ongoing activities
- Drive execution of Risk Adjustment projects including Retrospective and Prospective Medical Records Review and Risk Adjustment Data Validation (RADV)
- Manage process flow, project management, vendor execution and oversight, data submission and reconciliation with stakeholders
- Create, implement, and monitor policies, procedures, SOPs, performance guarantees, and workflows
- Maintain an up-to-date repository of Coding and Chart Retrieval documents
- Collaborate with Actuarial to project and monitor coding program impact on revenue and financial forecasts
- Coordinate processes and data flow between coding/chart retrieval teams and business partners to support follow up of care and quality activities
- Build relationships with internal teams, provider network, vendors, and customers; participate in engagement activities
- Prepare materials, analysis, reports, and presentations for committees, performance meetings, trainings, and newsletters
- Lead, develop, mentor, and manage the Risk Adjustment Coding and Chart Retrieval team
- May require travel to provider offices as necessary
Requirements
- 5 years of experience overseeing and driving Risk Adjustment Coding performance
- 7 years of experience working with Medicare Advantage Plans
- 7 years of experience with methodologies such as Clinical coding, clinical information management, project management, quality of care improvement, process improvements, financial analysis, operations
- 1 year staff, team lead or project lead experience
- Experience leading a team of direct reports, vendors, and relationships at all levels of management
- Mastery of CMS HCC Risk Adjustment coding and data validation requirements
- Master knowledge of ICD-10-CM coding guidelines, medical terminology, and clinical practice and processes
- Strong understanding of the Medicare and ACA Risk Adjustment models and Risk adjustment cycle
- Bachelor or master’s degree in nursing
- Certified CRC and/or CPC
- Strong proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point)
- Experience with Project Management tools and Teams/WebEx/ZOOM
- Excellent verbal communication and interpersonal skills
- Proven success building and maintaining positive relationships; collaborative team approach
- Strong organization, documentation, attention to detail, time management, and ability to handle multiple projects under pressure
- Analytical, solution-focused, creative, and compliance-oriented mindset
- Ability to work over 40 hours per week and occasionally lift/move up to 5 pounds
- May require travel to provider offices as necessary
