Manager, Risk Adjustment Coding

verawholehealth; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

verawholehealth seeks a Risk Adjustment Manager to lead the MRA team and oversee risk adjustment coding and quality assurance validation across programs.

The role involves managing staff, developing workflows, ensuring compliance with CMS/Medicare guidelines, and driving data-driven improvements in documentation and coding accuracy.

You will collaborate with multiple departments, mentor staff, and stay current with industry best practices to optimize health outcomes and reduce costs.

Qualifications

• Bachelor's degree or 3 years of equivalent related work experience.
• Active coding credential through AAPC or AHIMA (CRC preferred).
• Minimum 3 years coding experience in HCC coding.
• Minimum 2 years in a lead/senior role.
• Strong knowledge of medical terminology, anatomy, physiology, disease processes, and pharmacology.

Responsibilities

• Subject matter expert for risk adjustment coding and CMS data validation.
• Manages daily department staff and provides feedback to the Director of BOI.
• Oversees hiring, onboarding, and staff discipline processes.
• Develops provider performance measures via data reviews and analysis.
• Ensures adherence to official guidelines and procedures.
• Mentors staff to meet performance requirements and quality standards.
• Provides resources to staff to meet quality and production goals.
• Contributes to reporting on chronic conditions, provider rates, and coder variability.
• Identifies and develops tech to enhance risk adjustment operations.
• Keeps updated on Medicare guidelines and coding regulations.
• Leads coding education and training initiatives for staff.
• Researches best practices and maintains currency in coding literature.
• Evaluates and recommends enhancements to risk adjustment program and guidelines.
• Develops new workflows and policies to support initiatives and audits.
• Leads workgroups and manages project deliverables.
• Reports project status to the Director and flags risks.

Skills

Risk adjustment coding

CMS data validation

Leadership

Communication

Project management

Education

Bachelor's degree

AAPC/AHIMA credential

Tools

MS Office

EMR systems

Job description

Job Description Summary

The Risk Adjustment (RA) Manager reports to the Director of Burden of Illness (BOI). S/he performs duties to conduct the day-to-day management of the MRA Team Supervisors and team functions by communicating with other operational departments and provider offices. S/he will participate in the development, implementation, and performance of workflows for reviewing electronic medical records aimed at improving the health and well-being of patients through appropriate identification of chronic disease conditions. This role will collaborate with all areas of the organization to ensure success of our value-based coding initiatives such as provider engagement, education, prevalence rates, documentation compliance and medical margin. He/she will support and further enhance the data and reporting model to capture and optimize ICD-10 reporting to payers to improve quality for our patients and reduce healthcare costs.

This position manages risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

• Prospective medical record review
• Concurrent outpatient claim diagnosis coding
• Retrospective medical record and provider response reviews

How will you make an impact & Requirements

Responsibilities

• Subject matter expert for proper risk adjustment coding and CMS data validation
• Provides daily management of department staff and provides feedback to the Director of BOI on exceptional and/or substandard performance.
• Oversees and ensures completion of all efforts associated with hiring, interviewing, onboarding, and recognition and discipline of staff.
• Execute on the continued development of provider performance measures on important aspects of care and service through data reviews and data-driven analysis.
• Provides ongoing feedback to staff on areas of success and improvement opportunities.
• Ensures that all members of the team are following official guidelines, policies, and standard procedures.
• Counsels staff on actions required to meet minimum performance requirements.
• Provides or arranges for necessary knowledge-based resources required by the department staff to meet quality and production standards.
• Contributes to the reporting for reassessment of chronic conditions, provider address rates, coder variability, and other risk adjustment coding related measure trends
• Participates in identifying and developing technology to enhance risk adjustment operations and accuracy
• Stay updated on changes to Medicare guidelines, coding regulations, and reimbursement methodologies to ensure compliance and accuracy in coding practices.
• Develop and lead coding education and training initiatives for staff to promote consistent and accurate coding practices across the organization.
• Research best practices in risk adjustment coding and reviews the professional literature for coding updates, maintaining currency in coding.
• Evaluates, researches, and recommends enhancements to the risk adjustment program and internal coding guidelines.
• Develops and implements new workflows and policies and procedures as needed to support new and existing department initiatives, audits, and projects.
• Lead workgroups and manage project deliverables for department initiatives, audits, and provider communications.
• Keeps department Director apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.

Qualifications

• Bachelor's degree or 3 years of equivalent related work experience
• Current active coding credential through AAPC or AHIMA required. ** Preference given to those with CRC designation.
• Minimum of three (3) years coding experience directly related to Hierarchical Condition Category (HCC) coding.
• Minimum of two (2) year experience in a lead/senior role
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems. This includes a comprehensive understanding of ICD-10-CM.
• Advanced skills for use of MS Office (Excel, Word, Access, and PowerPoint).
• Demonstrated ability to utilize a variety of electronic medical records systems.
• Ability to manage significant workload, and to work efficiently under pressure meeting established deadlines with minimal supervision. Strong time management skills. Must possess high degree of accuracy, efficiency, and dependability.
• Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization both verbally and written.
• Demonstrated organizational and problem-solving ability.
• Demonstrated experience in project completion, educational program development and/or group presentation.
• Commitment to maintaining confidentiality and adhering to ethical coding standards.

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