The Director of Clinical Documentation - Medicare Advantage is a key leadership position within the Finance department. The Director is responsible for setting appropriate risk scores for Medicare members where risk adjustment is permitted. Risk adjustment can be performed using prospective and retrospective methods and the Director is responsible for both. The Director is also responsible for coding and training policy oversight. Lastly, the Director must oversee the mission-critical function of building and monitoring the risk adjustment data validation (RADV) function, whose soundness will significantly mitigate compliance and financial risk to the organization.
Partner with Health Plan's and BSW executive leadership to plan the strategic direction of Medicare initiatives to facilitate achievement of the business goals and objectives and success criteria for the future.
Evaluate and oversee the development and implementation of CMS, HHS, and HHSC risk adjustment program changes at the health plan. Incorporate changes and requirements into strategy.
Use analytics to define Risk Adjustment focus at the health plan. Identify areas at both the health plan and hospital system to increase quality and maximize opportunities.
Coordinate and support test planning and execution activities related to ICD-10 enterprise implementation across multiple teams, business units and technical teams.
Educate internal and external stakeholders on changes in regulations and the critical nature of risk adjustment, and recommend areas of process improvement.
Maximize return on investment in Risk Adjustment operations by reducing reliance on vendors and increasing validity of data submissions.
Develop performance targets for both internal and external constituents. Ensure that performance targets are set and included in contracts where appropriate. Track progress against stated goals and drive to attainment.
Direct the development of key analytics and data to support Risk Adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization.
Develop and distribute provider report cards for key provider groups as it relates to Risk Adjustment metrics and performance. Develop and implement employee training and provider outreach programs, as needed, to improve Risk Adjustment performance.
Serve as the health plan subject matter expert in projects and initiatives. Performs other position appropriate duties as required in a competent, professional and courteous manner.
KNOWLEDGE, SKILLS, and ABILITIES
Will possess broad managed care experience with the ability to assume direct accountability for a risk adjustment function in a rapidly growing program. This includes a commitment to cultivating business relationships (internally/externally) while leading and motivating a team to achieve agreed-upon results.
Knowledge of coding, HCCs, risk adjustments concepts, medical record review project management, encounter data management, compliance audit concepts. Achieves Results: Reflects a drive to achieve and outperform. Continuously looks for improvements. Accepts responsibility for actions and results.
Problem Solving: Analyzes interrelated elements of problems and works systematically to solve them, uses sound judgment to develop efficient and feasible resolutions to challenging issues.
Analytical: Works to understand a complex situation, issue or problem by breaking it down into smaller pieces. Uses a step-by-step approach to evaluate consequences and implications.
Demonstrated capability to work cross functionally within corporate matrix environments, confirmed by references who will speak to effective collaboration and partnership on complicated initiatives.
Relationship Building: Able to develop and maintain relationships with a variety of types of positions and individuals at the health plan and health system.
Project Management: Sets goals and develops timely, appropriate and actionable plans, including adequate milestones and measurements for accomplishing them.
Bachelor's degree or equivalent experience
5 plus years experience
Certified Professional Coder
Internal Number: 18017563
About Baylor Scott & White Health
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!