GENERAL SUMMARY
Responsible for developing, implementing, and evaluating the policies and procedures used for the Medicare Risk Adjustment program to ensure compliance with all Centers for Medicare and Medicaid Services (CMS) guidelines.
ESSENTIAL RESPONSIBILITIES
- Manages the Hierarchical Condition Category (HCC) revenue function by developing and implementing policies and procedures for raising Risk Adjustment Factor (RAF) scores while ensuring the score accurately reflects the membership health profile.
- Provides corporate oversight for the Health Plan level Medicare Risk Adjustment programs.
- Develops and implements processes and procedures to ensure the accuracy and completeness of the Medicare Risk Adjustment data, and to ensure compliance with all CMS regulations and guidelines.
- Develops and maintains documentation of the Medicare Risk Adjustment process. Modifies the documentation as needed to ensure adherence to current and future CMS compliance requirements.
- Provides corporate oversight for the Risk Adjustment Data Validation audits conducted by CMS.
- Assists with the development of monthly revenue accruals related to the risk adjustment activities.
- Remains current with new developments concerning Medicare regulatory issues.
- Participates in the annual budget process. Responsible for the efficient use of the department’s resources to meet the strategic requirements of the business.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree or equivalent experience.
- Previous (7-10 years) related experience in medical record documentation review, diagnosis coding, and/or auditing with at least (2 years) prior experience in Medicare Risk Adjustment.
- Previous (3+ years) management experience required.
- Knowledge of Medicare/CMS regulations required.
- Knowledge of ICD-9 and CPT codes required.
- Demonstrated analytical and leadership skills.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Executive/Senior Level Officials and Managers
Primary Location: , , US
Organization: 37200 - Coventry Product Services, Inc
Schedule: Full-time
Job Posting: 2012-11-19 00:00:00.0
Job ID: 1212264