Supervisor Strategic Risk Adjustment and Quality

Company: Highmark Inc.

This job is responsible for developing plans and managing activities in support of Risk Adjustment and Quality/HEDIS. Directs the daily activities of direct reports supporting Risk Adjustment Coding and Quality/HEDIS. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement. Implements strategic and tactical improvements to the Risk Adjustment Coding and Quality/HEDIS processes.

Manages information that will ensure accurate and efficient projects. Responsible for working with appropriate departments in the areas of risk adjustment, compliance, process improvement and member/provider satisfaction for all product lines. Recommend and/or implements process improvements related to the potential of quality medical care and service. Serves as a resource regarding government and regulatory audits, accreditation standards, and continuous quality improvement principles.

Co‑ordinates audit and accreditation activities on behalf of the organization. Oversees the Performance of special studies per audits, conducting provider office visits and medical records reviews. Conducts specialized provider office visits for provider education on Risk Adjustment and Quality/HEDIS measures. Oversees the development and implementation of risk adjustment and risk mitigation education related to medical record documentation, risk adjustment, Quality/HEDIS.

Review of provider office/entity process for appropriate submission of ICD
10, CPT, and HCPCs codes according to government and coding guidelines.

• Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day‑to‑day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Provide day‑to‑day managerial oversight for staff responsible for Risk Adjustment coding and Quality/HEDIS activities. Ensure continuous improvement of processes and delivery of results within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimize the use of resources in assigned area using proven resource management techniques.
• Contribute to the department’s strategic planning efforts by identifying tactical opportunities for improvement, recommending solutions, and developing materials especially directed at Risk Adjustment, Quality/HEDIS, and Medical Record Documentation projects related to the development and implementation of educational opportunities. Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Oversee the development and implementation of complete, accurate, and fair QA standards for all medical coders.
  
  Maintain Productivity and team QA scores and report to leadership.
• Oversee the teams’ processes to conduct multiple type of audits, government and internal, identify gaps, repeating issues and communicate results in provider office sites with data analysis from office site and/or medical record reviews to (a) continually improve the care, service to members and patient satisfaction; (b) coordination with other Highmark programs for credentialing, quality improvement programs, value based programs, care management programs, to achieve high caliber results, and (c) ensure medical records meet regulatory requirements.
  
  Consults with providers as needed to ensure identified gaps, or chart deficiency trends are outlined, communicated, discussed and provider staff trained on correct procedures.
• Participate in initiatives requiring cross‑functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners. Assess the…