The posting
Job Description
JOB PURPOSE
The Risk Adjustment Manager will act as the subject matter expert for risk adjustment and coding. They are responsible to track, report, and collaborate with managers across On Lok PACE to ensure that all risk adjustment activities and workflows are performed in accordance with On Lok PACE business rules, CMS and DHCS rules and regulations, and the decisions of the On Lok PACE risk adjustment and encounter data reporting steering committee.
ROLES AND RESPONSIBILITIES
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Manage all aspects of the risk adjustment program, including developing process workflows, establishing and tracking program performance and ensuring program complies with applicable internal and external governing rules and regulations.
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Analyze claims data to provide analytics within the scope of risk adjustment to the completeness of risk adjustment data and to implement Risk Adjustment training and programs.
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Correct and reduce data submission errors.
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Supervise Risk Adjustment Analysts to provide thorough monitoring, report findings of chart audits, and opportunities to communicate improved documentation and coding practices back to providers and staff.
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Support ongoing retrospective and prospective audit system to assure improved documentation and coding occurs in a timely manner.
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Collaborate with cross-functional departments (Health Plan Services, Business Intelligence, Regulatory Affairs, and Compliance, and Quality Assurance) to ensure transparency and continuity of policy enforcement for all risk adjustment procedures.
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Assist with the documentation of coding-related departmental policies and procedures, both general and specific to all risk-adjusted lines of business.
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Serve as risk adjustment coding subject matter expert for Medicare, Medi-Cal, and health plans, both in day-to-day operations, the On Lok PACE risk adjustment, and encounter data reporting steering committee.
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Remain cognizant of current and emerging regulatory changes as it relates to Risk Adjustment, Coding, and RADV audits.
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Evaluate and oversee the development and implementation of CMS and DHCS risk adjustment program changes; incorporate changes and requirements into policies and strategies.
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Evaluates and manages risk adjustment vendors; acts as project manager for risk adjustment related projects/implementations.
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Use analytics to define risk adjustment focus areas. Identify areas to increase quality and maximize opportunities.
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Develop performance targets metrics for both internal and external constituents. Track progress against stated goals and drive to attainment.
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Develop and distribute provider reports for the steering committee as it relates to risk adjustment metrics and performance.
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Hires, trains, coaches and evaluates the performance of direct reports.
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Collaborates with CMO and Medical Directors to review risk adjustment focus areas and opportunities for improved documentation and coding.
REQUIRED QUALIFICATIONS
Education
Education Level
Education Details
Bachelor's Degree
in business, health administration, health policy, finance or a related field is required.
Work Experience
Experience
Experience Details
4-7 years
Minimum of 5 years of experience in Medicare risk adjustment.
4-7 years
A minimum of 5 years of medical coding experience.
4-7 years
Both Medicare and Medi-Cal experience.
Knowledge, Skills and Abilities
KSAs
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Coding Certificate required: either CPC or CRC from AAPC or CCS from AHIMA.
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Extensive knowledge of ICD-10-CM coding guidelines.
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Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.
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Excellent organizational, project, and program management skills; experience leading change and implementing programs.
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Strong quantitative and analytical skills with the ability to communicate data concisely and clearly to a variety of audiences.
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Demonstrated familiarity with the utilization of electronic health records systems and their applications.
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Ability to manage significant workload and work efficiently with minimal supervision.
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Proficient in Excel, Word, and PowerPoint programs.
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Demonstrated ability to be an effective, collaborative partner with internal and external stakeholders.
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Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels within the organization.
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Experience working across sectors, in a fast-growth, fast-paced environment, and/or in a highly complex, matrixed organization.
PREFERRED QUALIFICATIONS
Education (Preferred)
Education Level
Education Details
And/Or
Master's Degree
in related field.
Knowledge, Skills and Abilities (Preferred)
KSAs
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CRC is strongly preferred.
About Us
On Lok
Dedicated to The Care of Elders:
On Lok is a not-for-profit organization founded in the early 1970s by a group of citizens concerned about the plight of elders and the lack of long term options in the community. On Lok serves as the administrative arm of a group of five affiliated non-profit organizations. Its functions include research and development, human resources, fundraising and management information systems.
We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.
Join our team of leaders to begin a rewarding career!
On Lok's Employee Benefits include (eligible for any position for 20 hr/wk or more):
- Medical, Dental, and Vision coverage
- Retirement Savings Plan 403(b) and Term Life/AD&D Insurance
- Flexible Spending Account, Commuter Benefits, Pet Insurance and Employee Discount Program
- Mental Wellness Resources and Employee Assistance Program(EAP)
- Holidays (10 per year), vacation time, sick leave, and long-term disability insurance, and additional benefits are available
Your final compensation offer will be determined based on factors such as skills, experience, education, and licenses/certifications. The pay range is expressed as an hourly rate regardless of FLSA status. Exempt positions are paid salaried and are not subject to overtime.
Pursuant to the San Francisco Fair Chance Ordinance, and state and federal laws (including federal PACE requirements at 42 CFR 460.64(a); 460.68(a), we will consider for employment qualified applicants with arrest and conviction records.
On Lok is an equal opportunity employer committed to a diverse and inclusive workforce. All applicants will receive consideration for employment without regard to sex (including pregnancy), race, religion, color, gender, gender identity, gender expression, sexual orientation, national origin, ancestry, disability, medical condition, genetic information, marital status, age, military or veteran status, or any other legally protected status.
If you require reasonable accommodation to participate in the job application or interview process, to perform essential job functions and/or to receive other terms, privileges or benefits of employment please contact Recruitment ([email protected]).
