To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences and Financial Stewardship by
monitoring overall Risk Adjustment and HEDIS efforts.
The individual will provide superior quality by performing external provider audits pertaining to risk adjustment as well as performing internal audits on Risk Adjustment and HEDIS department’s medical record reviews.
The individual will be responsible for daily operations pertaining to the Comprehensive Health Assessment program and Clinical Documentation Program including but not limited to\: provider/office staff training, review and coding of CHA’s and records submitted for Clinical Documentation Program, referrals and Provider Education and feedback regarding medical record documentation and gaps pertaining to HEDIS measures.
The individual will provide superior customer experience by educating internally and externally of errors and opportunities for improvement discovered during routine auditing.
This individual will work closely with Management to implement benchmarks, establish acceptable thresholds, and effective quality assurance programs.
Maintain a quality assurance program for data collected by the Risk Adjustment and HEDIS Departments.
Assist with monitoring the performance of the Risk Adjustment and HEDIS Teams and report findings to Senior Leadership in a timely, consistent and effective manner ensuring that appropriate changes are implemented.
Does Well = Properly audits files in accordance with schedu
Improvement Required = Fails to properly audit in a timely manner.
Support audit processes ensuring work flows and results are properly documented and maintained.
Identify process improvements as needed.
Maintain confidentiality in regard to individual error results.
Assist in the development of an effective training program regarding correct coding techniques and data collection methods.
Assist with training new auditors as needed.
Perform chart reviews as needed.
Participate in CMS audits of our Risk Adjustment activities, including by not limited to Risk Adjustment Data Validation audits.
Act as a Subject Matter Expert on all things related to Risk Adjustment and HEDIS.
Assist with the tracking and reporting of identified compliance questions, issues, audits, and investigations through the use of compliance tracking software.
Utilize the compliance tracking software at HFHP, to include the monitoring of data entered into the system to ensure accuracy, developing and maintaining data entry workflows and manuals and providing additional training to users.
Assist in the development of a monthly Compliance Program Report to effectively capture current activities, issues, trends, and oversight related to compliance issues within HFHP.
Assist in the development and distribution of annual Risk Assessment surveys for various departments within HFHP.
Provide feedback and education on coding practices identified during routine audits.
Act as a Subject Matter Expert on all things related to Risk Adjustment and HEDIS for internal staff and Senior Leadership.
Conduct special studies/projects as requested by Senior Management and identify opportunities for operational improvements consistent with Health First strategic goals.
Assist in the maintenance and creation of policies and procedures relating to the Compliance program at HFHP, and participate in the oversight of all HFHP’s departmental policies to ensure compliance with established State and Federal regulations.
Ensure data submitted by Risk Adjustment and HEDIS teams is complete, accurate and thorough.
Ensure financial impact to organization is accurate and mitigate risk of regulatory agency audits by validating data submitted for Risk Adjustment and HEDIS measures.
Other duties as assigned
Bachelor’s degree in relevant field of study preferred or 3-5 years related work experience.
Certified coder with a minimum of 2 year's coding experience.
xpert knowledge of Risk Adjustment and/or HEDIS.
Research and problem resolution skills.
Personal computer skills a must, proficient in word processing, graphics and spreadsheet manipulation and basic understanding of the Internet.
Exceptional interpersonal relationship skills.
Demonstrates excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style.
Presents professional image to the public.
Experience in initiating, developing and monitoring policies, internal control procedures and operating standards.
Ability to navigate constructive conversations on behalf of the health plan with State and Federal officials.
PAHM or other health care related certification preferred. Will be required within 1 year of employment.