- San Francisco, CA, USA
- 53.36-71.14 per hour
- Full Time
On Lok PACE
We are a non-profit committed to our participants.
Dedicated to The Care of Elders:
PACE (Program of All-Inclusive Care for the Elderly) was developed to answer the many problems around caring for frail seniors. The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in their community whenever possible.
Seniors, their family members, and caregivers face many issues, including transportation to appointments, management of medications, coordination of medical care from different specialists, lack of social interaction, and ability to stay alone at home. On Lok PACE participants receive in home care services and transportation to a On Lok PACE center for primary medical care, social and recreational activities, and other senior care services.
We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.
Join our team of leaders to begin a rewarding career!
POSITION SUMMARY: The Encounter Risk Adjustment Operations Manager will act as the subject matter expert for Risk Adjustment and coding. They are responsible to track, report, and collaborate with managers across On Lok PACE to ensure that all risk adjustment activities and workflows are performed in accordance with On Lok PACE business rules, CMS and DHCS rules and regulations, and the decisions of the On Lok PACE risk adjustment and encounter data reporting steering committee.
DUTIES / RESPONSIBILITIES:
- Manage all risk adjustment activities, including developing process workflows, establishing, tracking issues in a manner that complies with applicable internal and external governing rules and regulations.
- Analyze claims data to provide analytics within the scope of risk adjustment to the completeness of risk adjustment data and to implement Risk Adjustment training and programs.
- Correct and reduce data submission errors
- Supervise Risk Adjustment Analyst to provide thorough monitoring, report findings of chart audits, and opportunities to improve documentation and communicate coding back to providers and staff.
- Support ongoing audit system to assure improved documentation and coding occurs in a timely manner.
- Collaborate with cross-functional departments (Health Plan Services, Business Intelligence, Regulatory Affairs, and Compliance, and Quality Assurance) to ensure transparency and continuity of policy enforcement for all risk adjustment procedures.
- Assist with the documentation of coding-related departmental policies and procedures, both general and specific to all risk-adjusted lines of business.
- Serve as risk adjustment coding subject matter expert for Medicare, Medi-Cal, and health plans, both in day-to-day operations, the On Lok PACE risk adjustment, and encounter data reporting steering committee
- Remain cognizant of current and emerging regulatory changes as it relates to Risk Adjustment, Coding, and RADV audits
- Evaluate and oversee the development and implementation of CMS and DHCS risk adjustment program changes; incorporate changes and requirements into strategy.
- Responsible for the overall business workflows that meet internal business needs and governmental regulations, procedures, and requirements. Evaluates, contracts, and manages vendors.
- Use analytics to define risk adjustment focus. Identify areas to increase quality and maximize opportunities.
- Develop performance targets metrics for both internal and external constituents. Track progress against stated goals and drive to attainment.
- Develop and distribute provider reports for the steering committee as it relates to risk adjustment metrics and performance.
- Manages end-to-end Risk Adjustment and cross-functional project management and scope. Monitors established operations, tracks performance, and resolves deficits.
- Hires, trains, coaches, and evaluates the performance of direct reports.
- Manage the department's strategic and operational goals.
- Implement and communicate direction for goals, policies, and strategy for achievement.
- Motivate and lead department staff performance and escalate issues as necessary.
- Strategically and systemically handle staff development and performance.
- Anticipate challenges and put a strategy in place to resolve in a timely manner.
QUALIFICATIONS (knowledge, skills, abilities):
- Minimum of 5 years of experience in Medicare risk adjustment
- A minimum of 5 years of medical coding experience.
- 4 yearsBoth Medicare and Medi-Cal experience.
- Coding Certificate required: either CPC or CRC from AAPC or CCS from AHIMA. CRC is strongly preferred.
- Extensive knowledge of ICD-10-CM coding guidelines.
- Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.
- Excellent organizational, project, and program management skills; experience leading change and implementing programs.
- Strong quantitative and analytical skills with the ability to communicate data concisely and clearly to a variety of audiences.
- Demonstrated familiarity with the utilization of electronic health records systems and their applications.
- Ability to manage significant workload and work efficiently with minimal supervision.
- Proficient in Excel, Word, and PowerPoint programs.
- Demonstrated ability to be an effective, collaborative partner with internal and external stakeholders.
- Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels within the organization.
- Experience working across sectors, in a fast-growth, fast-paced environment, and/or in a highly complex, matrixed organization.
On Lok's Employee Benefits include (eligible for any regular position for 20 hr/wk or more):
- Medical, Dental, and Vision coverage
- Retirement Savings Plan 403(b) and Term Life/AD&D Insurance
- Flexible Spending Account, Commuter Checks, MLA scholarships, Employee Assistance Program (EAP)
- Pet Insurance and additional discounts
- Holidays (10 per year), vacation time, sick leave, and long-term disability insurance
Your final compensation offer will be determined based on factors such as skills, experience, education, and licenses/certifications. The pay range is expressed as an hourly rate regardless of FLSA status. Exempt positions are paid salaried and are not subject to overtime.
Pursuant to the San Francisco Fair Chance Ordinance, and state and federal laws (including federal PACE requirements at 42 CFR 460.64(a); 460.68(a), we will consider for employment qualified applicants with arrest and conviction records.
On Lok is an equal opportunity employer committed to a diverse and inclusive workforce. All applicants will receive consideration for employment without regard to sex (including pregnancy), race, religion, color, gender, gender identity, gender expression, sexual orientation, national origin, ancestry, disability, medical condition, genetic information, marital status, age, military or veteran status, or any other legally protected status.
If you require reasonable accommodation to participate in the job application or interview process, to perform essential job functions and/or to receive other terms, privileges or benefits of employment please contact Recruitment (email@example.com).