Risk Adjustment and Performance Manager

Summary

Join Harbor Health as the Manager, Risk Adjustment, where you will drive process improvements and system enhancements, leveraging your expertise in healthcare data and operational processes. You will serve as a subject matter expert, ensuring compliance with regulatory requirements and optimizing encounter submission performance. This role involves managing a team, conducting risk adjustment training, evaluating medical records, and collaborating with various teams to achieve business objectives. You will also be responsible for maximizing health plan reimbursement and ensuring compliance with all applicable laws and regulations. Harbor Health offers a competitive salary and benefits package, along with professional development opportunities and a collaborative work environment.

Requirements

• Bachelor’s degree in a relevant field of study or commensurate work experience
• 5+ Years’ experience in RA Coding and Auditing
• 2+ Years’ experience managing teams
• Certified Professional Coder (CPC)

Responsibilities

• Monitor overall team performance; project production, coding quality, and pace of projects observing industry standards, regulatory deadlines, business objectives
• Collaborate and participate with multiple teams throughout the business to improve operations and promote business objectives
• Create and conduct risk adjustment training for new hires and existing direct reports to improve performance, quality, and team efficiency
• Delegation, management, and ownership of risk adjustment project volumes and pace
• Evaluate a variety of medical records and provider documentation to ensure validity and accuracy of ICD-10- CM codes
• Review project performance; identify and escalate coding and platform trends to management, manner to promote resolution and convey education
• Align team performance following State and Federal regulatory guidance to ensure Risk Adjustment activities are compliant with all applicable laws, regulations, rules and policies
• Support coding and auditing teams to meet our goals, CMS regulations and quality standards for Medicare Advantage and ACA Risk Adjustment, including provider education, coding, auditing and referrals along with the daily operations of the Risk Adjustment coders and auditors
• Support the review and delivery of provider audit results with education observing regulatory/accreditation/operational requirements
• Compliance with all applicable laws and regulations
• Maximize health plan reimbursement by management of Risk solution vendors and products including attainment of SLAs
• Hire, develop, and coach employees for results delivery
• Detail-oriented, initiative-taking, and capable of working independently as well as part of a team

Preferred Qualifications

• 4+ Years’ experience as the subject matter expert in areas of Commercial (ACA) Risk Adjustment
• 2+ Years Experience with Electronic Health Records (EHRs) and Clinical Continuity of Care Documents (CCDs)
• 3+ Years’ experience in leading the Risk/Encounter submission process
• Partner with our business leaders to design and implement business metrics and dashboards, with the highest standards of analytical rigor and data integrity
• Familiarity with Texas Department of Insurance (TDI) rules, regulations, and laws strongly preferred
• Experience in the start-up phase of a health plan preferred
• Strong Excel and PowerPoint background
• Experience in developing test cases
• Background in vendor implementations

Benefits

• Opportunity to shape, develop and mentor individuals to grow their career and impact their lives
• Collaborative and dynamic work environment
• An organization made up of people who are passionate about changing the healthcare landscape
• Competitive salary and benefits package
• Professional development and growth opportunities
• A transparent and unique culture