Quality Assurance Manager

Job Description A bit about this role:

We are hiring a Quality Assurance Manager to support the QA function within Devoted’s Risk Adjustment organization. This person owns the quality assurance program for our retrospective coding and auditing operations: the policies and SOPs behind it, the team that runs it, and the findings it produces. You will direct the work of a team of QA Reviewers, own the QA relationship with internal operational leaders and vendor partners (including AHS off-shore coding teams), review escalated charts yourself or facilitate further escalation, and turn findings into education and process changes that raise coding accuracy across the department.

You will also inform how technology is used to assist this work in accordance with our acceptable use policy.

• Serve as an expert on ICD-10-CM coding guidelines, AHA Coding Clinic guidance, and internal risk adjustment guidance
• Oversee an offshore FDR vendor team of QA Reviewers: set accuracy and productivity standards, review performance against them, and adjust volume allocation based on results
• Escalate staffing, training, and quality gaps to vendor management, which owns hiring, onboarding, and day-to-day supervision
• Own and maintain Devoted’s QA policies and SOPs for coding quality, retrospective coding, and audit operations (operational and subject matter owner; subject matter owner for the others)
• Plan QA review coverage and sampling across internal staff and vendors, including AHS off-shore coding teams, so that samples are representative and review volumes are met
• Perform QA reviews of escalated, disputed, and high-risk charts, and serving as the internal authority on coding disagreements the team cannot resolve; ensuring diagnoses selected for review are appropriate, accurate, and supported by clinical documentation
• Own the monthly and quarterly QA Scorecard process: accuracy of the findings, delivery to Risk Adjustment leadership, coders, and vendor leaders during meetings, and follow-through on remediation plans
• Identify documentation and coding trends across reviewers and vendors, present them to department leadership, and convert them into education, job aids, or process changes
• Run the review of individual QA work so the QA team’s own accuracy is measured, and incorporating material findings into the QA process going forward
• Partner with vendor leadership on quality expectations, corrective action, and escalation when performance does not meet standard
• Own timely resolution of coding questions from sources coding on behalf of Devoted, and maintaining the log of questions and answers as outlined by policy or procedure
• Partner with technology and analytics teams on risk adjustment tooling, including AI-assisted coding: define QA requirements, test releases and enhancements, and provide feedback on design and performance, within acceptable use policies
• Build and run monitoring for tools in production, tracking performance drift and error patterns concentrated in specific conditions, chart types, providers, or member populations
• Support retrospective coding and audits by abstracting medical records or ICD-10 codes for submission to CMS when volume or complexity requires it
• Recommend process improvements and preparing department reporting so productivity and quality goals are met or exceeded and operational efficiency is optimized
• Serving as a voting risk adjustment coding SME member on Devoted’s Coding Steering Workgroup
• Act in an ethical manner as required under HIPAA’s Privacy and Security rules, handling patient data with uncompromised adherence to the law, including what member data may be sent to which vendor systems
• Perform other related duties as required