Director Risk Adjustment, Coding & Quality

Company

Highmark Inc.

Job Description

JOB SUMMARY

This job develops and implements long-term strategy to achieve continuous improvements as it relates to Quality and Coding for the Highmark Health Enterprise. Ensures that Highmark'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 others established at the state and federal levels. Drives efficient operational functions to achieve established Quality measures, STARS and HEDIS performance ratings. Directs and manages team of ~75 employees that are health plan and community-based (embedded into provider systems) to deliver the highest quality of care to Highmark members and improve clinical documentation accuracy and completeness. Creates a culture focused on Compliance and Core Behaviors. Builds strong partnerships with Highmark cross-functional teams including Care Management, STARS, Compliance, clinical leadership of health systems, physicians and vendors to develop programs that deliver measurable, actionable solutions resulting in improved accuracy of medical record documentation and coding. Promotes the strategy and capabilities to develop risk management and physician / member initiatives that support provider documentation and coding accuracy. Executes audits performed by government agencies (e.g., CMS, HHS), internal Compliance and other validation audits to ensure efficacy of documentation, coding and quality for Highmark members. Develops and implements provider education strategies and tools, monitoring provider performance, developing corrective action plans, direct provider interventions, and assisting physicians and offices that perform below quality benchmark.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities including, but not limited to involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Quality Improvement Specialist (QIS) Program Vision and direction for leading embedded coder/ clinicians within provider offices. Serve as escalation to providers who require intervention.
• QIS Program intended to equip physicians with chronic member conditions to be reviewed during an upcoming encounter. Outcome of program is to ensure complete / accurate assessment and documentation of member profile.
• HEDIS Abstraction Primary liaison with Highmark's Quality/ Stars team for retrieval and abstraction of HEDIS charts. Execution of HEDIS abstraction is a critical component to Enterprise achieving 5 Star Ratings. Oversee and coordinate team of coder/ clinicians to facilitate chart collection and abstraction. Serves as escalation to provider offices and provides regular updates to Quality/ Stars team.
• CMS Audits - RADV and IVA Oversee the collection and validation of historical member clinical data to fulfill CMS audit requests. Includes retrieval of medical records, validation of member clinical conditions and confirmation of reimbursement values received from CMS. Responsible for overseeing operational efforts and providing status / results to Chief Compliance Officer.
• Provider / Vendor Education Lead interventions to address quality concerns relating to Provider and Vendor clinical information. Compose and distribute education materials to physician and vendors to aid the collection of complete and accurate member profile documentation.
• Production Coding Manage a team of internal coder / clinicians that perform Risk Adjustment coding of medical records. Track production coding results and monitor accuracy of coding.
• Quality Assurance on RPM Programs coding results Lead team of coder/ clinicians to review member medical records to validate 100% of new diagnoses submit table to CMS for reimbursement. Oversee operations to track and validate multi-pass quality review of validation leading up to external audit of Highmark Inc. financial statements.
• Vendor Quality Auditing Responsible for validation and enforcement of vendor quality SLA thresholds and remediation. Engagement with vendors to review results and remediate concerns.
• Compliance Oversight Oversee staff devoted to ongoing updates / policy modifications distributed by CMS. Serves to alert relevant stakeholders and propose new operational policy/ process updates to comply with regulatory mandates.
• Other duties as assigned.
  
  

EDUCATION

Required

• Bachelor's Degree in Business Administration/Management
  
  

Substitutions

• 6 years of relevant experience in lieu of Bachelor's Degree
  
  

Preferred

• Master's Degree in Health Administration
  
  

EXPERIENCE

Required

• 7 - 10 years in the Healthcare Industry
• 5 - 7 years in Management
• 5 - 7 years in Risk Revenue
  
  

Preferred

• 3 - 5 years in Consulting
• 3 - 5 years in Operational Excellence
  
  

LICENSES AND CERTIFICATIONS

Required

• AAPC, Certified Professional Coder (CPC)
  
  

Preferred

• AAPC, Certified Risk Adjustment Coder (CRC)
  
  

SKILLS

• CMS Regulations
• Presentation Delivery
• EHR
  
  

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Does Not Apply

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting up to 10 pounds

Occasionally

Lifting 10 to 25 pounds

Rarely

Lifting 25 to 50 pounds

Rarely

Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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