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Manager Risk Adjustment Coding Job

Date: Mar 16, 2019

Location: Eagan, Minnesota, US, 55122

Company: Blue Cross and Blue Shield of Minnesota

About Blue Cross



At Blue Cross and Blue Shield of Minnesota, we are developing industry-leading strategies every day that make a healthy difference in people’s lives. Blue Cross has a legacy of improving health through innovation because we believe that everyone should have the opportunity to live the healthiest life possible. Chartered in 1933 as the state’s first health plan, we’ve been serving the health care needs of Minnesotans for more than 80 years.



Blue Cross supports you with competitive pay and a comprehensive benefits package. Many Employee Resource Groups are active in the company, promoting inclusion and helping us meet the diverse needs of our workforce and our members. Join us, and enjoy a work environment where all employees are respected and valued — a workplace honored with a perfect score on the Human Rights Campaign Corporate Equality Index for 2017. Find your place at a company that cares.



 


Description Summary

This position supports the enterprise risk adjustment optimization activities across business segments.  This position drives operations objectives by:




  • optimizing the receipt of earned risk adjusted revenue for risk adjusted segments 

  • enabling improved accuracy in understanding the illness burden of membership to enable other plans to better manage their members illness burden and risk



This position leads a team to review patient records to capture and code for accurate risk adjustment revenue, conducts audits of provider and vendor records to ensure accuracy and completeness, and ensure operational readiness for government audits of our risk adjustment practices.  The incumbent will manage employees, including skill and career development, policy administration, discipline, employee relations, goal setting, and performance reviews.


Accountabilities


  1. Lead a team responsible for all quality assurance, provider, vendor, and government audit functions to support enterprise risk adjustment optimization across business segment populations in the following areas:

    • Perform all administrative duties related to the planning, scheduling, and conducting audits and maintaining records associated with audits of medical records for risk adjustment reporting.

    • Review patient records in accordance to published standards to analyze provider documentation to ensure that it meets standards and supports the diagnosis and procedure codes selected.

    • Conduct audits on abstracted files to ensure accuracy and completeness of coding by identifying accurate coding opportunities and rechecking all diagnoses and procedures using ICD-CM (ICD-9 and ICD-10) and CPT-4 codes, and mapping to relevant HCC and/or CDPS categories.



  2. Prepare and implement necessary internal controls for related entities consistent with CMS and State requirements to support regulatory audits.

  3. Manage vendor and provider audits with regard to risk adjustment and prepare a summary of findings to leadership.

  4. Perform quality assurance reviews of audit findings and provide guidance on medical record review issues.

  5. Conduct periodic risk adjustment workgroups, especially when changes have been made to the risk adjustment models(s), CMS and other regulatory guidance, coding guidelines, etc.

  6. Manages audit work in accordance with accepted industry practices, and contractual and licensure agreements.

  7. Directs the team, including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training.  Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.


Requirements


  • BA with 5 years work experience in provider office medical coding/claims or auditing clinical records or 9 years of  provider office medical coding/claims or auditing clinical records work experience in lieu of a degree.

  • 3 years of staff and/or project leadership experience.

  • Experience with risk adjustment coding and methodology.

  • Strong experience with ICD-9 and/or ICD-10 coding, medical record review and audit, quality assurance of clinical practices and experience with Medical Records.

  • Knowledge of healthcare quality regulatory requirements and related to government agencies.

  • Excellent business communication and relationship skills, including experience leading collaborative teams, building long-term collaborative relationships, and managing external relationships with vendors and regulatory agencies.

  • Ability to track and manage work to ensure work is completed as required and deadlines are met.

  • Successful staff management experience, with excellent performance management and coaching skills.


Preferred Requirements


  • Registered nurse or related health care qualification preferred.    

  • Additional certifications such as (not limited to) CRC, CPMA, RHIT, RHIA, CCA, CCS.

  • Specialty clinic experience.

  • Proficient knowledge of CMS-HCC , HHS, HCC, and CDPS-Rx model and guidelines.

  • Current knowledge of industry audit standards and in-depth understanding of statistical sampling methods and risk adjustment methodology.

  • HEDIS or Stars experience.

  • Demonstrated ability to apply critical thinking skills to coding policy interpretation and implementation.

  • Ability to travel (locally and non-locally) as determined by business need.



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FLSA Status

Exempt


Blue Cross Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Make a difference



Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day



Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association


Nearest Major Market: Minneapolis

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