Remote-Ready Risk Adjustment QA & Auditing Lead

Excellus BCBS; City of Utica (NY); Hybride; USD 90 000 - 140 000; Plein temps

Avantages offerts par ce poste

Remote work possible

Résumé du poste

Excellus BCBS in New York seeks a Supervisor of Risk Adjustment Quality Assurance and Auditing to oversee a team of QA auditors, ensuring coding accuracy and regulatory compliance across CMS, ICD-10-CM, and internal guidelines.

The role leads training, performance management, and process improvements, partners with leadership to drive efficiency and quality in IPM, CON RADV, and HRADV audits, and supports a strong privacy and ethics framework within the organization.

Qualifications

• Five (5) years ICD-10-CM and HCC coding experience required and experience in CMS and HHS Risk Adjustment Data Validation Audits (RADV and HRADV).
• Prior experience supervising or managing people and/or projects or indirectly leading teams.
• Associate’s degree in a health care related field preferred.
• CPC and CRC certifications required. Other current coding certification (CPC-H, CPC-I, CCS, RHIA, or RHIT) preferred by AAPC or AHIMA.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology. Knowledge of healthcare industry.
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems.
• Possess extensive knowledge of CMS and HHS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements.
• Strong written and verbal communication skills; strong analytical, organization and time management skills required.

Responsabilités

• Provide strategic oversight, supervision, and support to a team of Risk Adjustment Quality Assurance Auditors, ensuring all audit activities strictly adhere to state, federal, and corporate standards.
• Direct and coordinate the day-to-day operations of the Risk Adjustment QA Audit team, ensuring coding accuracy, regulatory compliance, and consistent application of CMS, ICD-10-CM, and organizational guidelines.
• Oversee risk adjustment audit activity including monthly internal coding quality audits and all federal and state risk adjustment data validation audits including, but not limited to, Improper Payment Measure, Contract-level RADV, Department of Health and Human Services RADV (HRADV).
• Documents and defines audit project expectations and parameters for the Risk Adjustment Quality Assurance Auditors in keeping with department, corporate, state, and federal deadlines.
• Assists the Risk Adjustment Coding Educator Manager and Training Lead in identifying areas of opportunity for external business partners and internal coding and audit staff for coding and audit education based on internal quality assurance and state and federal audits.
• Provides coaching, mentoring, and ongoing training to audit staff to enhance coding knowledge and audit performance. Conducts performance evaluations, goal setting, and regular feedback conversations via quarterly check-ins.
• Ensure audits are conducted in accordance with CMS guidelines, ICD10-CM Official Coding Guidelines, risk adjustment coding standards, and organizational policies.
• Monitor audit quality, accuracy rates, and turnaround times. Assist in review of complex cases, as necessary.
• Serves as a subject matter expert for Risk Adjustment Audit and Coding. Advises staff on proper audit and coding practices through informal discussion and project validation.
• Evaluates day-to-day workload and processes to maximize productivity and efficiency ensuring all deadlines are met. Assists leadership verifying and reporting staff productivity, quality and assigning audit due dates, setting project expectations, and monitors staff for timely project completion.
• Develops corrective action plans, training material, and performs training as needed. Maintains staff and departmental quality and volume related statistics and provides documentation to departmental management.
• Functions as a backup quality assurance auditor for risk adjustment audit functions and assists with day-to-day work as needed. Executes audit projects in support of the Risk Adjustment Department strategy.
• Identifies and recommends the development of new processes, as necessary. Continually seeks and suggests process improvements to drive audit accuracy and productivity.
• Coordinates and performs all RADV audits and other audits as requested.
• Keeps management informed of project activities through regular written and oral status reports. Proactively identifies risks that may hinder audit success. Reports to the Manager Risk Adjustment Coding and Auditing on team and individual audit accomplishments, barriers, progress, and training needs.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts regular staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Connaissances

ICD-10-CM coding

HCC coding

RADV/HRADV audits

People management

Training & development

Regulatory compliance

EMR systems

Analytical skills

Communication skills

Project coordination

Formation

Associate's degree in health care

CPC and CRC certifications

Additional coding certifications

CDEO certification (preferred)

Outils

EMR systems

Description du poste

Excellus BCBS in New York seeks a Supervisor of Risk Adjustment Quality Assurance and Auditing to oversee a team of QA auditors, ensuring coding accuracy and regulatory compliance across CMS, ICD-10-CM, and internal guidelines.

The role leads training, performance management, and process improvements, partners with leadership to drive efficiency and quality in IPM, CON RADV, and HRADV audits, and supports a strong privacy and ethics framework within the organization.