Risk Adjustment Provider Engagement Lead

Position Summary:

The Risk Adjustment Provider Engagement Lead is responsible for building relationships with our external physicians while conducting medical record reviews, monitoring, and analyzing coding patterns, and providing onsite education. Provide coding expertise as well as administrative oversight to improve the overall quality of the documentation; ensuring that it is to the highest level of specificity in accordance to the CMS guidelines.

General Duties/Responsibilities (May include but are not limited to):

Validate provider documentation for accuracy by reviewing and analyzing samples of coding and claims extracts compared to actual medical records.

Track and report progress of the chart reviews performed on the external physicians to assure the coding accuracy and quality of the data submitted to CMS is accurate to the highest level of specificity.

Develop education materials to assist physicians in accurately assessing patients' overall health status.

Provides feedback to providers on performance improvement opportunities; tracks and prioritizes projects to improve coding and documentation outcomes.

Maintain a comprehensive tracking and management tool for assigned physicians within Alignments Healthcare provider network.

Identify issues, determine impact to Risk Adjustment models, and report results timely to ensure that physicians remain in compliance.

Conduct onsite provider education and training regarding Risk Adjustment to help ensure and increase the accuracy of the member's health status.

Present progress and results to leadership on a routine basis.

Assist with CMS Risk Adjustment Data Validation activities to ensure our external physicians and Alignment Healthcare is prepared for and will pass an audit.

Regularly update all Risk Adjustment materials with clinical and/or official guideline changes.

Suggest, update, and enhance clinical educational materials to assist in training physicians and clinical staff on Risk Adjustment Healthcare Programs including CMS-HCC Models, Clinician Chart Reviews, and Encounter Documentation.

Suggest customizations of Risk Adjustment education for various audiences; Support Staff, PCPs, Specialists, Employees vs. contracted and Central Departments

Stay current of industry coding, compliance and HCC issues.

Utilize, protect, and disclose Alignment Healthcare patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; and participating in professional societies.

Other duties as assigned to meet the organization's needs.

Supervisory Responsibilities:

N/A

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Minimum Experience:

a. Three-five years of coding in a medical group or health plan setting required; Professional Coding experience required.

b. Previous use of Epic, Allscripts, EZCap a plus

c. Proficient user in MS office suite, MS access a plus

d. Local travel is required

2. Education/Licensure:

a. Bachelor's degree in Business Administration, health Care Management or in a related field or equivalent experience preferred.

b. A nursing degree is preferred.

c. Licenses/Certifications: CPC, CPC-H, CCS, CCS-P, RHIT, RHIA, OR CPMA required.

3. Other:

a. Experience with strategic planning in risk mitigation.

4. Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.