Individual & Family Plans – Quality Review and Audit Manager
Description: • Manage day-to-day performance of a team of coding auditors (~8) within Individual and Family Plans (IFP) Risk Adjustment Operations • Ensure delivery of accurate data and attainment of strategic objectives for risk adjustment • Ensure compliance with coding guidelines, federal and state regulations, and quality standards • Oversee external coding partners to meet accuracy standards and compliant application of coding rules • Develop and deliver coding education to address gaps or deficiencies • Participate in Risk Adjustment activities and projects and lead coding strategy and process improvement efforts • Own, develop, and implement coding projects supporting data submissions to government oversight agencies and internal & RADV audits • Lead cross-functional coding initiatives, liaise with matrix teams, and cultivate business partnerships • Coach, train, and hold team accountable for adherence to coding guidelines and HHS risk adjustment rules • Determine, monitor, and manage coding performance metrics; ensure 95%+ accuracy and compliant external partner performance • Manage KPIs, report trends and challenges to leadership, and recommend optimizations in technologies, programs, processes, and people • Serve as Subject Matter Expert for projects, lead platform implementations, and translate complex coding concepts into actionable guidance • Resolve complex coding and data challenges using independent judgment and drive removal of roadblocks Requirements: • High School diploma required; Bachelor’s degree or higher preferred • 5+ years minimum coding experience required • Certification by AHIMA or AAPC in one of: CPC, CCS-P, CCS-H, RHIT, RHIA • Certified Risk Adjustment Coder (CRC) certification preferred • Supervisory or management experience required • Knowledge of CMS RADV audits; 2+ years RADV coding experience preferred • Familiarity with HHS (PPACA) Risk Adjustment highly preferred • Proficiency with CMS/HHS regulations and policies related to documentation and coding (Inpatient and Outpatient) • HCC coding experience and Risk Adjustment knowledge strongly preferred • Strong interpersonal, presentation, and communication skills (written and verbal) • Strong analytical and organizational skills; detail-oriented • Problem-solving skills and ability to identify coding issues and develop solutions • Ability to provide clear guidance through change and in ambiguity • Ability to work independently and collaboratively; relationship management skills • Proficiency in Microsoft Excel, PowerPoint, Word, and Adobe Acrobat • If working at home, internet via cable broadband or fiber optic with at least 10Mbps download/5Mbps upload Benefits: • Health-related benefits including medical, vision, dental, and well-being and behavioral health programs • 401(k) with company match • Company paid life insurance • Tuition reimbursement • A minimum of 18 days of paid time off per year and paid holidays • Eligibility to participate in an annual bonus plan • Remote work / Work at Home option (remote locations United States) Apply tot his job