- Serve as the primary authority on Risk Adjustment coding guidelines and manage all audits, including Risk Adjustment Data Validation (RADV)
- Lead the Quality Risk Adjustment Team in conducting risk adjustment audits in a remote setting
- Collaborate with various markets to establish and implement effective provider education initiatives
- Utilize data analytics to identify and address potential risk adjustment compliance issues
- Analyze data trends and develop action plans to address and prevent future risks
- Create QRA program dashboards and vendor QA reports utilizing key performance indicators (KPIs)
- Analyze provider and member data to ensure accurate Risk Adjustment Factor calculation
- Manage the development and implementation of processes to ensure accuracy and completeness of risk adjustment data
- Stay up-to-date on CMS and state regulations related to Risk Adjustment
- Recruit, develop, and motivate team members
- Collaborate with Legal and Compliance teams to identify and mitigate risks
- Implement strong project management practices to drive operational success
- Develop and manage Quality Risk Adjustment Provider Education program
- Use data analytics to identify provider-specific risk areas and intervention strategies
- Perform other job-related duties as assigned
- Bachelor's degree in Finance, Business Administration, or related field
- 7 years of healthcare experience, preferably in managed care
- 3 years of risk adjustment coding/auditing experience
- 3 years of team management experience in medical chart auditing
- Experience managing complex projects virtually and in-person
- Proficiency in Microsoft Excel
- Knowledge of CDPS-Rx and HHS/CMS Risk Adjustment regulations
- Familiarity with ICD-10 and CPT codes
- Strong project management skills
- Effective communication and analytical abilities
- Ability to work independently and prioritize tasks
- Excellent interpersonal skills
- Certified in medical coding: AAPC or AHIMA
- Project Management Professional (PMP) preferred
- General office environment; extended periods of sitting or standing may be required
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
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Senior Manager, Quality Risk Adjustment Programs - Dayton, United States - CareSource
Description
Job Title: Senior Manager, Quality Risk Adjustment Programs
Company: CareSource
The Senior Manager, Quality Risk Adjustment Programs is accountable for overseeing the Quality Risk Adjustment (QRA) programs and ensuring compliance across all business segments within the organization.
Key Responsibilities:
Qualifications:
Competencies and Skills:
Certifications:
Working Conditions:
Salary Range: $108,000 - $190,000
CareSource offers a competitive and comprehensive compensation package tailored to each individual's qualifications and the demands of the role. Employee well-being is a top priority, and we provide extensive benefits to support our team members.
Organization Level Competencies:
