Director, Government Programs Risk Adjustment & Audit

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

• Interface with Blue KC operational and clinical leadership to assist in identification of operational and coding best practices in chronic condition management, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding.

• Interface with external provider partners' operational and clinical leadership to assist in identification of operational and coding best practices in chronic condition management, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding.

• Provide Government Programs oversight to ensure Medicare Advantage and ACA Risk Adjustment and state regulations are maintained.

• Own the coordination and implementation of retrospective medical record retrieval and review campaigns, prospective provider education programs, regulatory audit activities, and compliance monitoring initiatives designed to ensure accuracy and compliance of reported conditions.

• Manage the team accountable for risk adjusted revenue initiatives and works cross-functionally with clinical and technical teams to develop the tools, processes, and reporting required to ensure a compliant risk adjustment program.

• Build and maintain the risk adjustment roadmap which defines the strategic initiatives, operational timelines and regulatory audit and oversight functions to meet risk adjustment regulatory requirements and drive program performance.

• Interpret and monitor state and federal regulatory guidance for risk adjustment, audit and documentation and coding accuracy standards.

• Provide oversight of the documentation and coding educational programs with performance tracking for internal coding operations and provider partners based on analytics and guidance for Risk Adjustment initiatives.

• Develop and deliver educational materials or programs for accurate documentation to support all Government Programs quality care gap closure.

• Oversee the formal (Interrater Reliability and Risk Adjustment Data Validation) and internal audit activities of coding/diagnosis data collected from professional and facility medical records to ensure proper coding and compliance with risk adjustment requirements

• Monitor risk adjustment vendors to ensure performance standards are met.

• Develop and maintain prospective programs to support ongoing assessment of chronic conditions

• Chair the Risk Adjustment Workgroup that partners with multiple stakeholders and business unit leadership to drive ongoing process improvement to ensure risk adjusted revenue optimization.

• Develop and manage budget; control expenses while meeting operational, financial and service requirements.

• Maintain expert knowledge of ACA risk adjustment regulations

• Maintain expert knowledge of Medicare Advantage risk adjustment regulations to support runout and future CMS audits.

• Ensures programs are established to support Blue Association host plan requests such as medical record retrieval and delivery of care gaps or conditions to the provider-facing Blue KC team and Association provider education requirements are maintained.

Minimum Qualifications

• Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, Information Systems, Business Administration or other relevant clinical academic field; or an equivalent combination of education and experience
• 5+ years of clinic or hospital experience and/or managed care experience.
• 5+ years' experience in Risk Adjustment and HEDIS / Stars coding
• 3+ years' team lead or project lead experience
• Certified Risk Adjustment Coder AND/OR Certified Professional Coder with the American Academy of Professional Coders with the requirement to have one and obtain both certifications, CRC and CPC.
• Advanced knowledge of ICD10-CM coding.
• Proficiency in MS Office (Excel, PowerPoint and Word).
• Must be able to work effectively with common office software, coding software, EMR and abstracting systems.
• Ability to travel locally up to 75%.
• Strong organizational skills, ability to prioritize responsibilities with attention to detail.
• Must be self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, strong follow-through skills and a solutions-oriented attitude.
• Innovative thinker with ability to articulate a vision, manage complexity, and lead change amongst internal and external stakeholders; Demonstrated experience in successful change management strategies.
• Ability to Develop Long Term Relationships
• Excellent Oral & Written Communication Skills
• Good Work Ethic, Desire to Succeed, Self-Starter
• Strong business acumen and analytical skills
• Ability to deliver training materials designed to improve provider compliance
• Ability to use independent judgment, and to manage and impart confidential information

Preferred Qualifications

• Master's degree in Business, Healthcare Administration or related field.
• Licensed RN (preferred) 3+ years nursing experience (Note: license must be current in Missouri & Kansas)
• Experience with a variety of EMR systems strongly preferred
• Ability to read and interpret medical records, including handwritten records
• Conscientious problem solver, willing to learn, takes personal pride in their work performance/accuracy
• Excellent verbal communication skills - clear, concise and appropriate
• 10 years of broad health care experience, to include health plan experience, provider payment, innovative payment design and data analysis.
• Previous development of clinical documentation improvement programs

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.