Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Risk Adjustment Program Coding Manager is responsible of the development, management, and execution of Capital’s Risk Adjustment Program Coding and Chart Retrieval operations driving high quality and performance outcomes thru improvements on our Medicare and Commercial/ACA end-to end clinical documentation, chart retrieval operations, retrospective and prospective programs, and data validation audits. This role provides strategic and tactical direction in collaboration with the Stars & Risk Adjustment Sr. Director and Medical Director. Function as a Risk Adjustment subject matter expert, manage work plans, perform analysis, market research, as well work with cross-functional teams in the development and implementation of efficient and effective standards, controls, tactics, initiatives, and systems, etc. to support ongoing improvements and ensure compliance to prevent, detect and mitigate compliance risks.

• Guide and oversees the creation, implementation, and monitoring process of the Risk Adjustment Program Coding and Chart Retrieval operations strategy, objectives, tactic, and initiatives to drive a year over year quality of care improvements, appropriate clinical documentation and reimbursement, and compliance with CMS mandates, regulations, and audits.
• Lead coding and chart retrieval teams to ensure performance at required accuracy and efficiency rates by designing and implementing on-going quality assurance processes and controls to proactively detect, remediate, and improve appropriate coding in adherence to compliance guidelines, regulations, standards, and policies and procedures.
• Lead risk mitigation and HCC compliance audits and on-going activities ensuring appropriate clinical documentation. Risk mitigation and HCC compliance evaluations might impact internal coding team, providers, vendors, etc.
• Lead coding and chart retrieval activities of Risk Adjustment projects. Drive execution and ensure success of Risk Adjustment projects including but not limited to: Retrospective and Prospective Medical Records Review, Risk Adjustment Data Validation.
• Manage Risk Adjustment Program Coding and Chart Retrieval activities including process flow and documentation, project management (retrospective, prospective, RADV, etc.), vendors execution and oversight, supports data submission and reconciliation with internal and external stakeholders. Creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency, scalability, and compliance. Maintain an up-to-date repository of Coding and Chart Retrieval documents.
• Acts as subject matter expert, maintain up-to date knowledge, and interpret applicable federal and state agencies regulations, CMS and HHS guidelines and requirements, Medicare, and ACA models, coding guidelines, etc. transferring knowledge to leadership, risk adjustment team, and cross-functional teams, etc.
• Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies. Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals.
• Ensure the coordination and management of processes, protocols, controls, and data flow between risk adjustment coding and chart retrieval team with appropriate business partners resulting in proper follow up of care and quality of care activities for our members.
• Build strong relationships across Capital teams, provider network, vendors, and customers. Active participant on engagement activities with providers, customers, and vendors in support of the Risk Adjustment Program. Collaborate in building materials, analysis, reports, and presentations for Committees, performance meetings, trainings, newsletter, etc.
• Lead, develop, and mentor the Risk Adjustment Coding and Chart retrieval team.
• Lead risk mitigation and HCC compliance audits and on-going activities ensuring appropriate clinical documentation. Risk mitigation and HCC compliance evaluations might impact internal coding team, providers, vendors, etc.

Skills:

• Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand. Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach. Ability to influence and persuade people to collaborate and execute toward a common goal.
• Strong organization and documentation, attention to details, ability to handle multiple projects and tasks simultaneously, time management meeting deadlines, even under pressure.
• Successful record of managing multiple projects with excellent results, meeting desired outcomes and goals. Eager to work with sense of urgency aligned with priorities, overcome obstacles, if needed seek for support early driving the best results to positive impact the Company and team goals.
• Ability to think analytically to resolve issues; solution-focused mindset; creative, innovative, and compliance thinker.
• Adaptability to an agile and dynamic work environment.
• Ability to prioritized tasks and shift readily between “big picture” and small-but-critical details. Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions.
• Strong proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Project Management tools, Teams/WebEx/ZOOM.
• Experienced leading initiatives, projects, and process changes at enterprise level.

Knowledge:

• Mastery of CMS HCC Risk Adjustment coding and data validation requirements.
• Master knowledge of ICD-10-CM coding guidelines, medical terminology, and clinical practice and processes.
• Strong understanding of the Medicare and ACA Risk Adjustment models and Risk adjustment cycle.

Experience:

• 5 years of experience overseeing and driving Risk Adjustment Coding performance.
• 7 years of experience working with Medicare Advantage Plans experience.
• 7 years of experience working with several of the following methodologies: Clinical coding, clinical information management, project management, quality of care improvement, process improvements, financial analysis, operations.
• 1 year staff, team lead or project lead experience.
• Experience leading a team of direct reports, vendors, and relationships at all levels of management, mostly mid-senior level.

Education and Certifications:

• Bachelor or master’s degree in nursing.
• Certified CRC and/or CPC.

Work Environment:

• Ability to operate a personal computer (PC), including proficiency in Microsoft Office Suite.
• Demonstrated ability to interact with other departments. Demonstrates openness, flexibility, problem solving, patience, and tact when dealing with providers, members and staff.
• Knowledge of risk adjustment principles and coding updates. Excellent written and oral communication skills.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

Other:

• May require travel to provider offices as necessary

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.