QUALIFICATIONS
Educational/Experience Requirements:
- Bachelor's Degree in Business Administration/Management, or 10 years of relevant experience in lieu of Bachelor's Degree. Master’s Degree in Health Administration preferred
- 12+ years in the Value-Based Healthcare Industry
- 7+ years management experience in Medical Coding and Clinical Documentation
- 7+ years in Risk Revenue and HCC Coding
- 5-7 years in Operational Excellence
- 3 - 5 years of claims experience as a biller or supervisory capacity
- AAPC, Certified Professional Coder (CPC)
- AAPC, Certified Risk Adjustment Coder (CRC)
- Current knowledge on all CMS billing/coding regulations
- Licensure/Certification (CCS-P, CPC, RHIA or RHIT)
Required Skills and Abilities:
- Expertise operating in a value-based care environment, with knowledge of coding guidelines, HCC payment models, and best practices in clinical documentation, auditing, coding and billing (J-codes, Z-codes and AWP)
- Vendor management for a disciplined line of sight, control and optimize revenue collection
- Thorough knowledge of anatomy, physiology, pharmacology and medical terminology
- Comprehensive knowledge of coding and billing practices and official guidelines, HCPCS, ICD-9/ICD-10 and CPT, HCC (Hierarchical Condition Categories), Medicare Risk Adjustment (MRA), Healthcare Effectiveness Data and Information Set (HEDIS), as well as requirements with emphasis on Center for Medicare/Medicaid (CMS), and Office of Inspector General (OIG)
- Auditing skills for quality and compliance
- Strong analytical background, as this individual will be counted on to create suspected HCC diagnoses lists and identify clinical opportunities based on trends in coding data. The diagnoses/problem lists are based on clinician medical records and should not be supplemented by additional areas.
- Current on all coding / billing regulations and best practices and be able to relay this information to the clinical team
- Proficiency in Microsoft applications, including Outlook, Word, Excel and Power Point
- Self-starter, proactive, who works quickly and accurately and will prioritize and meet deadlines effectively
- Professional demeanor and demonstrated leadership ability; composed and effective under pressure and able to adapt to new and changing business conditions
- Solid leadership, analytical, project planning and coordination skills
- High energy: demonstrates an ability to function in a creative, entrepreneurial environment and think outside the box
Travel requirements: 20% local or national travel required
Work Conditions: This position will work in a variety of settings, e.g. office. The noise level in the work environment is usually moderate. Requires prolonged sitting. Requires bending, stooping, twisting, kneeling, crouching, crawling and/or stretching from seated or standing positions. Requires eye-hand coordination and manual dexterity sufficient to operate medical equipment, frequently operates a keyboard, telephone, copier, calculator and other office equipment. Manual dexterity and coordination necessary to operated office equipment, telephone, keyboard, copier and calculator. Requires close vision, peripheral vision, and ability to adjust visual focus, hearing and smelling. Must be able to communicate information via telephone or computer. Requires moderate to intense concentration due to complexity. Must be able to lift and/or move up to 25 lbs.
The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.