Clinical Manager, Risk Adjustment

As the Clinical Manager for Risk Adjustment, you will be at the forefront of our mission to optimize clinical coding practices and enhance the efficacy of our Risk Adjustment Program. Your role involves leading initiatives to establish, develop, and maintain key operational standards, ensuring that clinical documentation and coding activities meet the highest quality standards and compliance requirements. This position can be remote.

$109,900.00 - $146,500.00 Annual

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability    
• Employer-matched retirement saving funds   
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care     
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth and career advancement    
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities     

What You Will Do

• Provides coding subject matter expertise and support to cross-functional initiatives and projects.
• Works with management to coordinate coding compliance oversight as well as Technology/Clinical Leadership in completion of workflow enhancements, changes, and new products.
• Provides updates to Risk Adjustment Stakeholders on program clinical coding and audit activities.
• Reviews internal control environment to ensure responsiveness and accountability for coding compliance; identifies opportunities for improvement and leads implementation of improvements.
• Identifies, corrects, and reports coding problems; makes recommendations to address ongoing problems.
• Educates and collaborates with our providers in the continuous review and implementation of clinical documentation best practices.
• Maintains accurate records of review activities; ensures reports and outcomes of Clinical Document Improvement (CDI) efforts are valid.
• Compiles, analyzes, and summarizes data from medical records into various formats; coordinates education and feedback to providers.
• Keeps abreast of changes and trends in risk adjustment coding requirements. Integrates updates into processes.
• Monitors and oversees implementation of regulatory changes and serves as a resource to the Coding and Clinical Documentation staff.
• Collaborates with key stakeholders to meet delivery dates and assists in the finalization of all internal and external audits.
• Produces training materials and plans interactive working sessions with Coding and Audit staff members as needed.
• Performs all duties inherent in a managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hire, promotes, and terminates staff and recommends salary actions as appropriate.
• Participates in special projects and performs other duties as assigned.

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Licenses and Certifications:

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or (CRC) Certified Risk Adjustment Coder in ICD-10-CM coding required
• License and current registration to practice as a Registered Professional Nurse in New York State required

Education:

• Associate's degree in nursing required

Work Experience:

• Minimum five years of claims coding and risk adjustment experience in a Medicare or provider organization required
• Prior experience with Risk Adjustment Processing System (RAPS), Encounter Data Processing System (EDPS), EDGE Server, Risk Adjustment Data Validation (RADV) Audits and all CMS, State, and other regulatory guidelines required
• Strong knowledge of EMR tools and ability to retrieve records associated with audit or review criteria required
• Demonstrated understanding of Risk Score impact to plan and prioritization of data to close diagnosis gaps required
• Demonstrated understanding of base of data points associated with the end-to-end process of plan payment required
• Experience in gathering requirements and creating policies, procedures, and workflows to drive a successful Risk Adjustment program required
• Proficient in Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and related Hierarchical Condition Coding (HCC) Methodologies required. Proficiency with Microsoft Office (Project, Word, Excel, PowerPoint, Outlook) required
• Demonstrated effective leadership, communications, and coaching skills required
• Demonstrated ability to establish effective working relationships with all levels in the organization required
• Experience in Project Management preferred