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　　Job Summary

　　This position is responsible for the overall management and implementation of various initiatives including, but not limited to, Risk Adjustment Programs, Accountable responsibilities include the overall development, refinement, maintenance, monitoring and oversight of Medicare, Medicaid and Retail/Small Group risk adjustment initiatives and operations. The position is responsible for all aspects of decision-making and implementation of medical record coding reviews and coding policies to maximize revenue for the organization Leads a cross-functional, multi-departmental team in identifying improvement opportunities for clinical provider training, medical record documentation, data gathering, suspect identification, and health plan reporting to ensure accuracy and compliance with CMS models and guidelines. This position will work closely with the Stars and Encounters Leaders to ensure integration and delivery of these strategies.

　　1. Accountable for the overall integration, management and implementation of the Medicare Risk Adjustment Program across HCSC (i.e. network management, customer service, clinical services, information technology, and finance departments).

　　2. Ensure development, implementation, and maintenance of policies and procedures to support all operations processes & procedures and monitoring adherence.

　　3. Directs, oversees and completes all aspects of Risk Adjustment Projects and Initiatives.

　　4. Develop, train and mentor staff members.

　　5. Develop and implements chart pull strategy and analysis for chart review including vendor identification and selection.

　　6. Oversee the following day-to-day risk adjustment related operational activities:

　　Operations of all RN and coder team reviewers, including decision support on coding issues.

　　Coding processes and procedures, ensuring that the diagnosis supports the medical necessity of the procedure.

　　Tracks and monitors all physicians' sign-offs after completion of review.

　　Participates in CMS user group calls and regional meetings.

　　Ensures that recorded forms are complete, accurate and in accordance with policy and procedures.

　　Analyzes data collection for patterns and trends to identify opportunities to improve documentation.

　　7. Develop, implements, and/or maintains documentation consistent with CMS regulations, company goals and policies.

　　8. Coordinate and completes CMS Risk Adjustment projects.

　　9. Monitor and summarizes progress of CMS Risk Adjustment projects and initiatives. Identifies and evaluates potential new programs and services to determine cost effectiveness and revenue potential.

　　10. Identify opportunities; provides guidance and suggestions for quality performance improvements in the collection and recording of clinical documentation.

　　11. Manage vendor relationships.

　　12. Manage annual CMS audit/data validation and RADV audit Risk Mitigation strategic initiatives.

　　13. Work with Data, Claims, Network, Provider Relations, Compliance and Legal areas to achieve objectives.

　　14. Communicate and interact effectively and professionally with co-workers, management, customers, etc.

　　15. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

　　16. Maintain complete confidentiality of company business.

　　17. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

　　Required Job Qualifications:

　　Bachelor's Degree

　　10 years of experience in health care, managed care, health insurance or strategic consulting

　　6 years' leadership / management experience; 4 years' experience in medical record review, case management, utilization management, managed care, Home Health, QA Review, HEDIS review; 4 years' experience with healthcare payment and coding methodologies (i.e. ICD-9, CPT, DRG and HCC coding).

　　Experience with managed care data systems and reports.

　　Experience with Medicare, Medicaid and Retail/Small Group Risk Adjustment process

　　Workflow analysis experience

　　Experience in leading operations, capital budgeting and financial forecasting.

　　Analytical, presentation and verbal and written communication skills.

　　Executive presence with the ability to influence inside and outside of HCSC.

　　Business and financial acumen.

　　Experience managing vendor relationships to improve and optimize and service levels.

　　Experience leading and formulating strategy with the ability to build strong connections with people and teams in all environments (internal, external, government).

　　Experience leveraging knowledge of the external market, competition and regulatory environment to create value for the enterprise

　　Preferred Job Qualifications:

　　Master's Degree

　　Project Management certification or equivalent industry recognized certification

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　　This is a hybrid role, in office 3 days/week*

　　Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

　　HCSC Employment Statement:

　　HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.