Director-Risk Adjustment

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

The Director, Risk Adjustment is responsible for the oversight, planning, implementation, and evaluation of a comprehensive process aimed at ensuring accurate medical record documentation and clinical coding standards for Independent Health. The Director is responsible for establishing an action plan to support Independent Health's risk adjustment program for all lines of business (Commercial, Medicare and Medicaid) to ensure accurate and consistent reporting to government agencies and reflect our member's accurate disease burden. This is accomplished through collaboration with internal and external stakeholders, consistent coding implementation, development and maintenance of coding guidelines, sample medical record reviews/targeted medical record reviews, provider coding education and the alignment of vendor-based risk adjustment initiatives. The Director functions to promote teamwork and accountability in a performance-based work environment and represent the Risk Adjustment area on cross-functional teams. Duties include, but are not limited to, strategic planning, risk-based decision making, hiring, staff training and development, monitoring workflows, performance evaluations, and coaching/mentoring and managing Team associates. The Director works closely with external stakeholders and all required regulatory agencies.

• Bachelor's degree required; RHIA or equivalent coding certification; and Clinical degree BSRN required.
• Eight (8) years of experience in clinical medical record coding with the demonstrated ability to identify diagnosis documentation and support, collect data and draw valid conclusions are required.
• Four (4) years of direct management experience required.
• Experience with medical record abstraction.
• Experience working with health plan medical management (case management and disease management) resources to ensure the appropriate referral of members with health conditions suitable for health plan medical management.
• Experience with ICD-9 and 10 coding rules and CMS HCC requirements are required.
• Solid understanding of documentation & coding standards and HCC & CRG methodologies required. Solid understanding of regulatory agency audit programs for risk adjustment data submissions.
• Previous health plan experience preferred.
• Working knowledge of health care delivery and insurance industry.
• Knowledge of federal and state laws and regulations regarding privacy and confidentiality of Protected Health Information and Personally Identifiable Information.
• Demonstrated ability to analyze data and deliver timely, accurate and relevant reports.
• Strong verbal, written and interpersonal communication skills required.
• Local travel may be required. Any Independent Health associate who uses a motor vehicle in the course of their duties representing Independent Health must be compliant with New York State Motor Vehicle laws and must follow the Policy that pertains to Driver's License Requirements as a condition of employment.
• Ability to work a flexible schedule required.
• Solid MS Office skills required (Word, Excel, Access, PowerPoint).
• Solid conflict management skills, with the ability to identify research and resolve associate issues and/or concerns.
• Demonstrated time management skills, with the ability to work in a self-directed manner.
• Project management and process improvement skills are preferred.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative, and Accountable.

• Develop, coordinate, and evaluate Independent Health's risk adjustment programs for all lines of business to ensure diagnosis coding accuracy, process integrity and clinical appropriateness while reviewing to assure compliance with CMS coding rules and other regulatory bodies. The above shall be accomplished while providing strategic, risk-based decision making to ensure alignment of cross-functional processes.
• Responsible for the planning, directing and strategic oversight of risk adjustment operations including the development of coding audit programs, targeted reviews, provider education, and regulatory audits (i.e. National RADV, Targeted RADV, ACA-IVA, OIG reviews).
• Work in collaboration with Independent Health Executive leadership and other Stakeholders for the development, implementation, coordination, and evaluation of Independent Health policies in support of accurate coding guidelines.
• Drives cross-functional efforts with internal resources and external vendors to develop the necessary infrastructure to support risk coding activities and reporting. Monitor the external environment to identify best practices for all phases of Independent Health's risk adjusted revenue lines of business with emphasis on improving the accuracy, capturing, and reporting of risk adjusted data. This includes participating in and leading various user groups such as ACHP, AHIP, RISE and direct discussions with other non-competing health plans.
• Provide a consistent approach to oversight, direction and decision making regarding Independent Health's third-party risk adjustment vendor partners.
• Analyze and interpret operational data to identify and implement process improvements to reduce rework and gain efficiencies and ensure accuracy of risk adjustment reported data.
• Provide ongoing oversight of data submitted for risk adjustment payment purposes including the identification and follow through for any potential overpayments requiring self-reporting or redaction.
• Create and maintain reports, dashboards and project plans necessary to ensure the successful operations and results.
• Lead the development of processes and education within physician offices to accurately code the appropriate patient disease burden for accurate risk factor assignment.
• Participate actively on cross functional teams to ensure accurate reporting and review of risk adjustment revenue and capture data on population risk.
• Provide ongoing matrixed reporting and progress updates to designated leadership (i.e. Finance, Government Product Operations, etc) as needed.
• Maximize productivity and provide opportunities for professional growth and development to achieve departmental goals. Ensure that inter-rater reliability assessments are performed for members of Independent Health's internal Risk Adjusted Revenue Operations team and vendor-based coding efforts.
• Manage within financial budget while maintaining accurate records and accounting of expenses within budget.
• Responsible for the day-to-day management and performance of assigned team, including developing motivating, coaching, and mentoring of staff.
• Oversee targeted coding reviews, feedback & education of practitioners/providers in support of best practice medical record documentation, coding, and adherence to guidelines.
• Ensure departmental compliance with regulatory standards and coding guidelines.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $130,000 - $170,000 annually

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.