Director, Clinical Excellence​/BOI

Job Description Summary The Director of BOI reports to the Director of Quality Programs. S/he is responsible for overseeing, coordinating, or perform data reviews and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine annual risk adjustment program strategies to achieve optimal performance. S/he should foster and maintain vendor and carrier relationship to help drive optimum program success and meet contractual obligations.

Identify areas of opportunity via reporting and workflow improvement throughout the organization. Collaborate between all areas of the organization to ensure success of our value-based coding initiatives such as provider engagement, education, prevalence rates, coding opportunities, documentation compliance and medical margin. The Director is tasked with improving the Risk Adjustment department through innovative technologies, leading, and growing the team and exploring future programs to enhance our position in Value Based Programs.

How will you make an impact & Requirements

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Ensure compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment.

Develop, Train and lead staff to review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify whether:

The diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.

The diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted timeframe.

Any diagnosis code identified as being unsubstantiated by the record must be submitted to the carrier within timely guidelines to ensure on supported codes remain on record with those carriers.

Review for clinical indicators and query providers to capture the severity of illness of the patient.

Measure Providers’ performance on important aspects of care and service through data reviews and data-driven analysis

Communicates and coordinates reviews with RA Provider Educator and Support Services for use in provider training sessions.

Facilitates and coordinates reporting to leadership within the organization as requested

Manages the BOI Team in a positive manner with emphasis on providing excellent service to all patients, providers, internal and external customers.

Communicates to supervisor and IT Department regarding defects identified in the reporting systems or data base, suggests performance improvement opportunities and tracks through completion to insure revenue capture.

Confirm code capture and proper RAF calculations by carriers.

Provides reporting for revalidation of codes, accept, and reject rates, code trends for areas of opportunity. Reporting by carriers, provider, POD, etc.

Assist with identifying and developing technology to enhance risk adjustment operations and accuracy Health plan ASM/EDS data submission or reconciliation

Provides clear, concise and professional communication to varying audiences depending on the project and its goals.

Demonstrates excellent time management, attends and contributes to required meetings which may include travel as well as hours outside of standard business hours and/or above 40 hours per week.

Demonstrates the ability to train new leaders or provide ongoing education and training to existing staff/leaders along with regularly performing quality reviews and including feedback on opportunities for improvement to the Risk Coding team.

Supervisory Responsibilities Directly supervises assigned employees in the Risk department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Competencies To perform the job…