Director of Risk Management and Revenue Integrity

Responsible for managing the Medicare Advantage risk adjustment process and encounter data processing (EDPS) in accordance with CMS regulations.

Requirements

• Manage the Electronic Data Processing (EDPS) data submission process
• Collaborate with coding staff & vendors to develop relevant coding guidance
• Establish and maintain HCC visit review program
• Responsible for responding to and overseeing CMS Risk Adjustment Data Validation (RADV)
• Develop and update department’s policies and procedures
• Assist with the development, implementation, and oversight of auditing projects
• Facilitate modifications to clinical documentation
• Review data and trends to identify additional areas of opportunity
• Deliver provider-specific metrics on Gap-closing opportunities
• Maintain knowledge of coding rules and program regulations
• Maintain vendor contracts and relationships
• Oversee vendor software users
• Monitor vendor progress and performance
• Assist with developing coding policies and long-term plan
• Coordinate and develop metrics related to risk adjustment operations
• Maintain knowledge of applicable current and proposed laws, regulations, and sub-regulatory guidance
• Draft and maintain policies and procedures, standard operating procedures, and work instructions
• Develop resolution and plan for action for identified raps and EDPS discrepancies
• Responsible for assisting leadership with implementation and oversight of risk adjustment and mechanism for projects

Benefits

• Health insurance
• Retirement plan
• Paid time off
• Holiday pay