The Director of Clinical Documentation and Risk Adjustment develops and directs medical coding, clinical documentation integrity, quality, and revenue integrity programs. This is a national leadership role that supports providers with a primary focus on relationship-based care while managing both fee for service and value-based care payment systems. The Director will establish system wide coding standards, policies and procedures related to charge capture, and professional coding and billing practices. This role will lead a team that provides complete and accurate coding, documentation improvement, and quality performance coding. This role will also provide education designed to promote complete and accurate reimbursement generated from ICD10, CPTI, and CPTII coding. This leader will provide revenue integrity oversight and guidance to the organization to ensure documentation and data quality, compliant coding and revenue cycle operational practices as required by Federal and state legal requirements and payer policies. Ultimately, success in this role comes from a combination of a passion for healthcare administration leadership, exceptional attention to detail and accuracy, top-notch data analysis and presentation skills, commitment to cross-functional teamwork, an outstanding service ethic and a desire to consistently improve in an organization that is dedicated to excellence. Requirements:
This leader will have the ability to bring about strategic change to meet organizational goals. Inherent to this is the ability to establish an organizational vision and to implement it in a continuously changing environment.
? Design and implement a comprehensive centralized national mid-revenue cycle strategy for the clinical operating model, organizational structure and services that incorporates a reasonable span of control and aligns with the organization's operational performance targets
o Interpret data, financial metrics and provide reporting to executive leadership.
o Work with leaders and IT to develop KPIs, performance dashboards, and reporting.
o Lead annual mid-revenue cycle strategic planning, strategy execution, and implementation of standardized processes and procedures to produce predictable high-quality financial outcomes.
o Partner with Chief Financial Officer, product team, engineering team, data science team, and external vendors to optimize revenue collection, both through direct input on revenue cycle management practices as well as changes to mid-revenue cycle implementation.
? Develop payer agnostic risk adjustment and HEDIS capture strategy.
? Develop coding, audit, and CDI practice standards, procedures, and policy with internal coders
o Oversee and operationalize coding and CDI programs to drive best practices for complete and accurate documentation of patient health status and demonstrate the exceptional care those patients receive.
? Develop and implement appropriate audit programs for provider services and coding quality.
? Develop and implement a process for medical staff query and follow up where appropriate
? Develop, scale, and implement outpatient prospective and concurrent coding and CDI processes.
? Manages coding edits and denials corrections and appeals and then communicate to clinical staff if necessary.
? Initiate, review, implement, and manage vendors for outsourced coding services.
? Assess potential and existing risks in regulatory and/or coding practices and answer questions and resolve coding, documentation and data quality compliance issues identified.
? Work with other team members to ensure the organization has and maintains appropriate security, confidentiality and compliance practices and takes appropriate measures to protect the organization's clinical data.
• Bachelor's degree in related field
• Certified Professional Coder (AAPC CPC or AHIMA CCS-P)
• 7 years progressive leadership in an outpatient healthcare environment
• 5 years of experience in Medicare Advantage
• Fluent in revenue cycle management and healthcare financial performance.
• Expert in documentation and coding requirements for professional services.
• Thorough understanding of the relationship between codes and revenue in the reimbursement process, specifically how revenue is generated from ICD-10CM, CPT, and HCPCS codes.
• Expert knowledge of current coding guidelines and federal and state reimbursement program requirements, CMS Conditions of participation, MACs, NCCI edits.
• Experience in researching complex coding compliance issues and questions.
• Ability to develop effective education programs for adult learners (coders, clinicians, clinical staff).
• Knowledge of business ethics and compliance risks and the ability to manage those risks in a dynamic health care environment.
• Requires excellent written, verbal and group presentation skills.
• Expert at MS Office Word, Power Point, Excel, and Outlook.
• Ability to travel 10-20% of the time.
• Clinical Master's degree
• Certified Risk Coder (CRC); Professional Medical Auditor (CPMA)
• Experience leading remote teams.