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Job Description:

Position Summary:  Responsible for educating and advising physicians and office staff in Medicare coding guidelines as well as revenue enhancement opportunities. Supervise Risk Adjustment Educators and program support to ensure department’s program is effective and meets the needs of providers.  Work in collaboration with outside resources and PHP Client Decision Support to determine reporting packages that assists practices in coding more effectively and accurately to maximize IPA revenue.  Obtains assistance from community experts, plans education and serves as a mentor/trainer to internal and external customers and vendors.

COMPETENCIES/Role-Specific Functions: 

COMMUNICATION

Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.

• Collaborates to develop plans and present to practices the Risk Adjustment program that reflects IPA ethical standards and Medicare guidelines. 

• Collaborates with Optum and PHP data analysts/Informaticists and PHP Arcadia team to determine meaningful practice-level reporting to assist in coding and code submission more effectively.

• Develops communication plan with specialist practices, billing companies, electronic medical record vendors to assure ongoing development that supports the risk adjustment model. 

• Works with contracted Medicare Advantage plans, Optum and other third party vendors to drive or supplement educational forums and train report use.

DECISION MAKING/JUDGEMENT

Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, communicates decisions to others.

• Identifies potential data flow obstacles within assigned practices and works with practice staff to develop action plans to assist practices in overcoming obstacles.  Involves PHP quality coaches to assist practices as needed. 

• Identifies and solves issues with other vendors/services (billing companies, clearinghouses, etc.) to remove obstacles that prevent maximum code extraction and submission.

TEAM LEADERSHIP  

Anticipates and resolves conflicts, turns team diversity into an advantage, uses unique team talents, defines processes and goals, works for consensus.

• Provides materials, answers questions and responds to requests from both internal and external partners. 

• Supervises Risk Adjustment Educators and program support to ensure work is timely, complete and that decisions regarding documentation and coding performance meet department standards. 

• Develops and measures methods to understand and improve inter-rater reliability surrounding record reviews and education messaging. 

• Identifies and communicates to manager any additional training needs for department to assure integrity of education provided.

PEOPLE DEVELOPMENT

Provides feedback and coaching, rewards hard work and risk taking, takes mentoring role, challenges and develops employees, accepts mistakes, provides visibility/opportunity.

• Completes regularly scheduled one on ones with Risk Adjustment staff to discuss current objectives, goals, obstacles and assists on helping staff where needed to continue to grow within the department.

• Performs in-depth review of staff visit preparation and messaging to providers, coaching for improvement and standardization whenever needed. 

• Assesses staff productivity and reports summaries and trends to department leadership. 

CUSTOMER FOCUS

Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.

• Is a primary resource for physicians and office staff to answer questions regarding risk adjusting codes and Medicare coding guidelines and code updates. 

• Develops high level, interactive relationships with assigned practices in order to maintain the engagement of assigned practices. 

• Maintains high level relationships with practices to assist them in understanding the importance of coding accuracy to overall patient care management and IPA revenue goals. 

• Provides coverage support to practices when assigned Risk Adjustment Educator is not available.

JOB KNOWLEDGE

Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues.

• Assists in the ongoing development and implementation of the Risk Adjustment training program used to educate physicians and office staff on coding techniques that accurately document and capture patient acuity to the highest degree of specificity while adhering to IPA ethical standards and Medicare guidelines.

• Other duties as assigned.

Qualifications (Education/Experience/Knowledge/Skills):

• Associates or Bachelors’ degree required.  RN preferred. 

• Certified Professional Coder  (CPC) required.  Certified Risk Adjustment Coder (CRC) preferred.

• Minimum of 2 years of experience in  Medicare risk adjustment. 

• Knowledge of risk adjustment categories and hierarchy.

• Minimum three years’ experience in a medical office and/or working with medical records, preferably electronic medical records.

• Knowledge of health care insurance claims practice and compliance.

• Knowledge of Medicare rules and guidelines.

• Knowledge of Claims Coding (CPT, HCPCs, Revenue Codes, ICD-9.ICD-10, UB92/HCFA 1500).

• Knowledge of MS Office Suite, other software programs and internet based applications as needed to fulfill position duties.

• Skilled in synthesizing data and questions to communicate a cohesive educational training program.

• Skilled in presenting and explaining data in a clear, concise manner.

• Skilled in interpreting Medicare rules and changes.

• Skilled in responding to practice inquiries in a timely and accurate manner.

• Skilled in working collaboratively with various parties to communicate an accurate and meaningful reporting package for practices.

• Able to work effectively with physicians, practice staff, health plan/other external parties and PHP multi-disciplinary team to streamline efforts to meet Risk Adjustment goals.

• Able to work with sensitive data and relay potential issues or concerns in a diplomatic manner.

• Able to multi-task and meet deadlines.

• Able to work with external parties to incorporate data elements into reporting package.

• Able to communicate findings in a clear, concise manner, both internally and externally.

• Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures.

• A valid unrestricted Colorado drivers’ license. 

• Reliable and insured vehicle.

• Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures. 

• Mobile Device for work purposes as defined by the company policies and procedures.

Salary Range:

$73,093- $91,366