Job Location: Strongly preferred in Denver, Colorado; Open to Remote for the right candidate
Travel Required: 10-20% (if remote).
Senior Manager, Healthcare Risk Adjustment Compliance
This is a leadership position responsible for several key areas of our day-to-day compliance program within this company's Integrated Kidney Care business unit, including:
- Risk adjustment compliance for CMMI and Medicare Advantage programs
- This company's IKC clinical operations and clinical IT/EHR compliance (e.g., clinical IT system design, implementation, and maintenance; and health information management (HIM), including medical records, and related medical documentation);
- Model of Care/clinical initiatives compliance; and
- Medicare Fee-for-service (MFFS) revenue cycle and billing compliance.
- Lead the compliance risk adjustment and FFS revenue cycle compliance monitoring and auditing plans, including development, implementation and management of all related initiatives;
- Design and implement compliance monitoring data analytics supporting revenue cycle and risk adjustment;
- Lead quarterly coding audit process and reporting (with support of external coding vendor);
- Lead annual compliance risk assessment process related to revenue cycle, risk adjustment, coding, and medical documentation for DaVita IKC;
- Lead and support IT/EHR compliance programs including, but not limited to, guidance on medical documentation and coding/billing compliance controls, monitoring and tracking of IT defects, and remediation of IT defects for Cerner platform;
- Assess and give guidance on compliance risk in related collateral (e.g., revenue cycle and risk adjustment business processes, training/communication material, and clinical model of care documentation);
- Design and implement billing, coding, and risk adjustment related policies;
- Design and implement provider outreach and education programs;
- Lead oversight of risk adjustment vendors or other related 3rd parties;
- Lead RAD-V and RAC audit preparedness (internal mock audits and external audit response)
- Bachelor’s degree required; advanced degree in Business Administration, Public Health, Healthcare Administration, or Information Management preferred
- Preferred 5+ years of healthcare experience (e.g., health plan and/or ACO managing risk adjustment for Medicare Advantage products), including tenure with a reputable management consulting firm with healthcare experience (e.g., forensics services, investigations, claims and disputes, compliance);
- Experience required working in healthcare industry dealing with federal healthcare program laws including the False Claims Act;
- Experience required with development, implementation, and maintenance of Medicare Fee-for-service and Medicare Part C risk adjustment compliance programs including, but not limited to, revenue cycle management, medical documentation and risk adjustment governance, coding guidelines, related policies, coder inquiries, medical documentation, and monitoring and auditing of medical documentation and coding;
- Experience designing and implementing data analytics related to revenue cycle and risk adjustment;
- Experience with medical coding including ICD-10 and HCC risk adjustment coding;
- Self-motivated, team player with proven ability to identify issues and manage priorities in a fast paced environment while striving for practical business solutions;
- Hands on, efficient and proven ability to “Get Stuff Done” with a bias for action and a strong sense of ownership.
- Required credential with the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).
- Required Certified Risk Adjustment Coder (CRC) certification.
- Other preferred skills and experiences include:
- Strong organizational and project management skills with demonstrated attention to detail;
- Experience designing, maintaining, or working with electronic health record systems including Cerner platform;
- Experience managing risk adjustment vendors or other related 3rd parties;
- Experience managing RAD-V and RAC audits;
- Experience conducting internal medical documentation and coding audits;
- Experience designing provider outreach and education programs related to medical documentation and coding;
- Experience with actuarial, finance, and/or operational activities of a health plan;
- Experience in positively and successfully managing relationships with a high energy and diverse group of leaders across organizational lines;
- Solid technology skills including Excel and PowerPoint including experience with creating data analytics;
- A thoughtful, articulate and effective communicator who can distill and articulate the important aspects of any issue to a wide audience of participants;
- Ability to quickly establish credibility and expert at quickly creating trusted advisor relationships with senior leadership to navigate complex matters;
- Superior written and verbal communication skills (including presentations) and the ability to drive execution in a team environment; and
- Demonstrated management level presentation experience.