Associate Director, Risk Adjustment Audit

Become a part of our caring community and help us put health first

The Associate Director, Risk Adjustment oversees quality assurance audits of medical records, ICD-10-CM, CPT, & HCPCS codes that are submitted to the Centers for Medicare and Medicaid Services (CMS), other payers, and over government agencies. In addition, the Associate Director, Risk Adjustment oversees all medical coding education activities. The Associate Director, Risk Adjustment requires a solid understanding of how organization capabilities interrelate across departments.

The Associate Director, Risk Adjustment ensures coding is accurate and properly supported by clinical documentation within the health record. Follows state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records. May participate in provider education programs on coding compliance. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s) and could lead multiple managers or highly specialized professional.

Responsibilities

Leads team of coding and documentation auditors who:

• Ensure coding is accurate and properly supported by clinical documentation with the health record.
• Ensure medical record documentation is accurate and complete.
• Follow state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records.
• Ensure organizational policies, procedures, and processes related to coding align with government, payer, and organizational requirements.
• Reviews data validation and other internal and external audits to identify trends and provide education when needed.
• Provides oversight and monitoring of potential coding issues (cancer, E&M utilization, etc.)
• Serves as coding resource to other coding teams; helps answer questions and resolve inter-departmental coding discrepancies.
• Provides audit oversight to newly acquired providers and provider groups when needed.
• Assists in other coding-related capacities as needed.
  
  

Audit Strategy

• Identify and recommend strategies for improving clinical documentation and coding for pre and post visit coding.
• Prepares quarterly audit reports, outlining quarter-by-quarter comparisons, trend identification, action plans, and other pertinent information.
  
  

Education Strategy

• Collaborates with clinical and coding education leaders to develop a PCO-wide strategy for coding education (includes Offshore and IPA providers and coders).
• Provide coding and process education to teams of medical coders, both onshore and offshore
  
  

Collaboration/Partnership

• Cultivates relationships with Divisional Coding Leaders, Market Leaders, and Consultative Coders to share knowledge and best practices.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction or guidance.
  
  

Post-Visit/Offshore Coding Collaboration

• Establish relationship with post-visit/offshore coding leadership.
• Develop continuous quality improvement initiatives to support improved documentation and coding.
• Partners with business associates from other departments to understand their needs and concerns and participates in the development of system solutions.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
  
  

Productivity And Quality Management

• Monitor auditing staff workload and redistribute resources as needed to meet market operational demands.
• Develops KPIs to monitor the performance of the audit team.
• Analyze trends and identify opportunities of improved auditing.
  
  

Associate Engagement And Retention

• Foster a positive work environment that encourages collaboration, innovation, and personal growth.
• Conduct regular feedback sessions, performance evaluations and career development discussions with coding staff.
• Assess employee concerns, resolve conflicts, and create initiatives to improve satisfaction and retention.
• Research and interpret correct coding guidelines and internal business rules to respond to inquiries and issues.
• Partners with clinical and coding education to develop training curriculum to support documentation and coding areas of opportunity.
  
  

Required Qualifications

Use your skills to make an impact

• CPC, CCS, or CCS-P Certification
• 6 or more years of technical experience in Physician Office Medical Coding and/or Auditing
• 2 or more years of Management experience
• Ability to travel both locally and overnight
  
  

Preferred Qualifications

• CEDO Certification
• CPMA or CRC Certifications are preferred, however, you MUST obtain these 2 certifications within the first 6 months to 1 year of employment.
• Bachelor's Degree in business in business, healthcare administration, or related field
• Well-versed in various reimbursement methodologies, including risk adjustment, fee for service, Medicare, etc.
• Passionate about contributing to an organization focused on continuous improvement.
• Proficient verbal and written communication skills
• Proficient in all Microsoft Office applications, including Word and Excel
• Public speaking / group presentation skills
  
  

Knowledge, Skills, And Abilities

• Comprehensive knowledge of all Microsoft Office applications, including Word, Excel, and PowerPoint
• Ability to communicate effectively and sensitively with clinicians and team members in stressful situations.
• Possess strong business acumen, excellent strategic thinking, and effective critical thinking skills.
• Excellent verbal and written communications skills with demonstrated ability to communicate, present, and influence both credibly and effectively at all levels of an organization.
• Ability to work in a rapidly changing, matrixed environment.
• Has a positive, collaborative mindset to foster partnership within and the Coding, Audit, and Education department, the PCO, and Humana.
  
  

Other Notes

• This is a Work at Home position that requires up to 20% Travel to different Centers in the Market
  
  

Schedule: Monday – Friday 8:00 AM to 5:00 PM

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$102,200 - $140,700 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description Of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.

About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.