Description
PURPOSE OF THIS POSITION
The Provider Education and Risk Adjustment Manager serves in a lead role to support provider education and documentation initiatives to support value-based programs. This position develops and implements provider education programs and processes to support documentation best practices through compliant documentation, appropriate code selection and accurate capture of clinical complexity to support value-based care program. This position supports the oversight of risk adjustment initiatives (HCC, RAF scoring), collaborate with coding teams and providers to ensure accurate capture of chronic conditions and quality measures identifying trends and actions plans for continuous improvement to support value-based programs (CIN, ACO) initiatives. This position collaborates and serves as liaison between providers, ACO and internal teams, including quality, coding, IT, clinical department leadership and compliance, to align goals.
JOB DUTIES/RESPONSIBILITIES
Duty 1: Designs and implements education programs for physicians, APPs, and clinical staff to support documentation best practices, ICD-10 coding, HCC capture, RAF scoring, payer requirements and quality reporting.
Duty 2: Collaborates with clinical departments to develop prospective, concurrent and / or retrospective workflows and processes through documentation improvement initiatives (CDI) to support comprehensive and specific capture of conditions to support optimal reimbursement, value-based programs, and quality reporting metrics. Implements processes for annual condition recapture, suspect analytics validation, and closing documentation gaps for chronic conditions
Duty 3: Creates and implements new provider onboarding program, including audits performed at regular intervals to identify coding and documentation opportunities; provides feedback and education to provider based findings.
Duty 4: Provides department and one-on-one provider coaching based on data insights (e.g., chronic condition / HCC capture, suspected conditions, identified documentation gaps, etc.). Supports education through various provider friendly communication methods and tools, such as creation of presentations, reference guides, newsletters, key performance indicators, etc.
Duty 5: Collaborates with HIM coding leadership and coding auditor and educator to identify coding opportunities to support HCC capture / risk adjustment coding; works with coding leadership to identify and initiate coder training and education on needed.
Duty 6: Collaborates with IT, provider oracle training team and internal teams to evaluate system optimization opportunities and implementation of tools to support provider in documentation accuracy and efficiency (e.g. creation of templates, upfront tools to support provider code selection and specificity, processes to capture chronic conditions, etc.).
Duty 7: Serves as a liaison with the CIN/ACO to support compliance with value-based care models, representing coding & documentation practices on behalf of BVHS and to address coding & documentation opportunities identified associated with RAF score.
Duty 8: Establishes dashboards and KPIs for documentation accuracy, coding quality, RAF trends, condition recapture, and quality metrics
Duty 9: Ensures compliance with regulatory requirements, including CMS, OIG, payer contracts, AHIMA Standards of Coding Ethics, HIPAA and internal policies.
Duty 10: This job description reflects the general nature and expectations for the position. It is not an exhaustive list of activities, duties, or responsibilities involved. The incumbent may be asked to perform other related duties as needed.
REQUIRED QUALIFICATIONS
Degree in Health Information Management, Nursing, Healthcare Administration, Health Informatics or other related field or equivalent work experience.
Three years' experience in HCC/risk adjustment related coding, clinical documentation improvement, provider and/or value-based care.
Required credentials include Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), Certification in Outpatient Clinical Documentation Integrity (CDEO or CCDS-O), or equivalent credentials or obtained within 12 months of starting position.
Hybrid work position with travel required between medical practices in the BVHS service area.
A valid driver's license is required (if you do not have a valid Ohio driver's license you must obtain one within 30 days of your residency in the state). You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
Possess advanced understanding of coding classification systems (ICD-10-CM, CPT, HCC, etc.), thorough knowledge of revenue cycle and reimbursement processes, including risk adjustment methodologies.
Understand audit standards and process, ability to perform trend analysis to identify opportunities and create actionable items to demonstrate improvement.
Strong knowledge of regulatory and compliance requirements; ability to seek out and research coding related topics through resources such as Coding Clinic, CPT Assistant, CMS websites, CIN/ACO resources, etc.
Ability to work independently and meet deadlines.
Ability to provide clear, concise, and effective education to individuals or groups. Skill in analyzing and effectively presenting data and complex information to various audiences, including leadership. Ability to build trust and credibility.
Capable of managing multiple tasks/projects with excellent organizational, time management, and prioritization skills. Self-motivated.
Proven proficiency with computer applications, including Microsoft Office (Excel, Word, PowerPoint), and healthcare-specific tools like Encoder.
Thrives in a fast-paced, creative environment, moving independently between tasks.
Makes sound decisions quickly, maintains professional conduct, and works well with others on both individual and team levels.
Positive service-oriented interpersonal and communication skills required.
PREFERRED QUALIFICATIONS
Experience with integrated health systems, ACOs, or Medicare Advantage plans, HHS ACS risk adjustment programs.
Familiarity with EHR workflows (e.g., Epic, Cerner) and clinical analytics tools (e.g., payer RAF portals, STARS dashboards)
Experience with Oracle (Cerner) and 3M 360E CAC program.
PHYSICAL DEMANDS
This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.
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