Risk Adjustment Coding Quality Director

The Risk Adjustment Coding Quality Director is responsible and accountable for the development, implementation, and monitoring of Coding Quality initiatives and training programs ensuring accurate and compliant coding practices. The Director will lead efforts to review and validate coding accuracy for the right reimbursement with internal staff, PCPs Medical Groups, and other resources. In addition, the Director will be responsible for managing the day-to-day operation of RADV audits, regulatory audits, and Risk Adjustment Vendor coding monitoring. Collaboration with multiple departments for operational efficiencies.

Develops strategies to Educate PCPs on HCC and Quality Metrics. Strategies should be focused on accurate coding and reimbursement related to encounters, chart reviews, and other clinical information sources. / 30%

Reviews and reports results of medical records reviewed by the coding team. Establish corrective action plans, if needed, based on results. / 15%

Develops analytics with actuarial teams to identify coding trends and prepare metrics / 10%

Reviews work plans prepared by the Medical Director based on the analysis results / 5%

Responsible for educational materials based on identified improvement areas and continuous education on best practices and emerging trends in risk adjustment coding. / 5%

Manages and provides direction to designated internal staff. This responsibility includes ongoing training, providing direction, and monitoring their productivity and their performance. / 5%

Supervises and reviews work analysis performed by the Medical Director and Risk Adjustment Coders.

Understands vendors' operations that are contracted for risk adjustment initiatives to evaluate their performance by CMS guidelines and educate providers on the use of their tools.

Prepares for and manages external audit processes including RADV.

Works with the Risk Adjustment Director to establish and/or modify risk score initiatives based on the analysis performed.

Develops and implements coding quality assurance protocols

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