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Humana Director of Risk Adjustment in Houston, Texas

Description

We help doctors do what they do best while engaging patients in their care.

At Conviva Care Solutions we recognize the need to simplify population health management for the people who provide health care. We support physicians and care teams, provider groups and integrated delivery systems with practical onsite services and solutions that help practices shift from a health care system built on treatment transactions to a value-based model built on better outcomes for patients more engaged as partners in their own care.

Responsibilities

Be a part of the Conviva Care Solutions Team, whose purpose is to provide population health management to physicians, physician groups, and integrated care delivery systems.

Conviva Care Solutions is seeking a Director of Risk Adjustment for the Texas/Louisiana area.

Primary responsibilities include:

  • Lead a regional team of coders responsible for all risk adjustment functions to support Conviva's risk adjustment optimization

  • Assist in the development, implementation and continually refinement of the pre and post chart review processes diagnosis coding initiative and provider support

  • Monitor and analyze the effectiveness of risk adjustment programs, processes, infrastructure, and reporting, making recommendations and implementing modifications to improve results and effectiveness.

  • Identify, evaluate, and implement new programs or modifications to existing coding processes and develop strategies to implement

  • Support the quality assurance, HEDIS and Stars company's initiatives in the workflow processes of risk adjustment

  • Collaborates with appropriate departments to develop, oversee, and adapt infrastructure (processes, systems, talent) to support an effective risk adjustment program as CMS evolves the model and guidance

  • Ensures coding team collaboration with the Auditing and Education department to ensure monitoring and training of coding accuracy and clinical documentation to ensure internal control consistent with CMS and State requirements to support RADV or other regulatory

  • Ensures coding team collaboration with internal departments and vendors to ensure complete and timely submission of claims/encounters to the health plan

  • Collaborates with internal departments as appropriate to develop and oversee the execution of strategies, programs and plans to engage the physicians in proper assessment, diagnosis coding and documentation of all patients

  • Utilizes analysis to identify trends and opportunities for improvement and further development of programs, processes and workflow impacting risk adjustment

  • Remains current and informed about CMS and industry trends and best practices, utilizing this knowledge to refine and advance the risk adjustment program

  • Accountable to maintain and ensure uniformity in the implementation process and clinical support MRA policies.

  • Establish regular communication with team and Area Medical Leaders to ensure effectiveness of work process and resolve ongoing issues

  • Responsible to identify and drive continuous improvement initiatives to achieve goals by leveraging operational, clinical, and corporate resources

  • Develop and maintains an influential and consultative professional partnership with Medical Leaders and Area Medical Leaders that improves documentation, coding, and gap closure

  • Responsible for the development of talent in the region to ensure the right person is in the right role to achieve regional and Conviva goals.

Required Qualifications

  • Bachelor's degree in business or health related area

  • Seven years (7) of proven leadership skills and supervisory experience

  • Ten years (10) of health care experience within a Health Plan or a Value Based provider setting

  • CPC Certified

  • Knowledge of healthcare quality regulatory requirements

  • Excellent business communication and relationship skills, including experience leading collaborative team

  • Strong interpersonal skills, with the ability to interact effectively with senior management, providers, and external partners

  • Knowledge of CMS Risk Adjustment rules and regulations for Medicare Advantage

  • Knowledge of CMS Risk Adjustment processes (RAPS, EDPS, RADV Audits)

  • Understanding of medical terminology such a s diagnosis codes (ICD-10), and other claims coding topics such CPT and HCPCS and related Hierarchical Conditions (HCC) methodologies

  • Advanced skills in Microsoft Office

  • Ability to travel as determined by the business

Preferred Qualifications

  • HEDIS/Stars experience

  • Experience in Project Management

  • Master's degree

  • Registered Nurse

Additional Information

Scheduled Weekly Hours

40

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