Shire Jobs

*POSITION SUMMARY *

Contribute to Health First Health Plans Risk Adjustment activities that support compliance with regulatory and contractual requirements specific to Medical Advantage (MA) and Individual and Family (IFP) Plans. The individual will be responsible for assisting leadership with daily operations pertaining to Risk Adjustment operational activities including but not limited to: executing training for new associates, new associate audits, special audits, oversee ongoing training, and special projects. This individual will work closely with leadership to help plan and meet communicated departmental goals and deadlines set forth by Centers for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS).

Primary Accountabilities

1. Execute leadership abilities by training, developing, and maintaining a team of Risk Adjustment Analysts responsible for the collection and submission of accurate diagnosis data to CMS and HHS.
2. Monitor and review all communication from federal and state authorities to identify and analyze revisions or new requirements to determine impact to strategy and first level tactical planning of the health plan’s position to effectively communicate updates to Risk Adjustment leadership.
3. Work closely with Senior Analysts and Value Capture leaders to ensure the quality of coding by Analysts meets department standards and ongoing training efforts.
4. Lead the work of others by prioritizing and delegating the daily workload to ensure completion of projects by stated deadline. Handle immediate situations to ensure departmental standards of quality, service and value are met.
5. Assist leadership in staff evaluation.
6. Develop relationships with key individuals (externally and internally) to foster an increased understanding of the Risk Adjustment process.
7. Act as a resource, and subject matter expert in Risk Adjustment (including but not limited to: payment methodology, submission requirements and their impact to the Health First Health Plans payments while having a working knowledge of HEDIS to assist Value Capture leaders in developing and maintaining best practices.
8. Research and implement process improvements that will maximize risk adjustment factor increases and avoidance of inaccurate risk adjustment plan payments.
9. Assist with the medical record retrieval and review process.
   10. Assist with ongoing training and education of Risk Adjustment Associates in order to increase awareness of the significance of Medicare Risk Adjustment (MRA) within the CMS Risk Adjustment model and IFP within the HHS Risk Adjustment model as well as the coding practices set forth by the Risk Adjustment production and quality standards.
   11. Uphold national regulatory and legal compliance by consulting validated coding references for accurate code assignment, i.e., ICD-10 Official Coding Guidelines, AMA Coding Clinic for ICD-10, medical dictionary, pharmaceutical and drug references, and anatomy and physiology references, etc by assisting Risk Adjustment leaders with internal and regulatory audits.

*MINIMUM QUALIFICATIONS *

• Education: High School/GED.
• Licensure: None required.
• Certification: o Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification. o Certified Risk Adjustment Coder (CRC) from AAPC.
• Work Experience: o 3 years of Risk Adjustment MA and IFP coding experience with knowledge of Risk Adjustment, CMS and HHS HCC Models and basic understanding of HEDIS. o ICD 10-CM auditing experience.
• Work Experience in lieu of Education: None

• Knowledge/Skills/Abilities :
  o Knowledge of Medicare and Individual Family Plan policies, processes and procedures. o Demonstrate effectiveness to communicate verbally and in writing professionally with all levels of the organization. o Strong analytical, collaborative, relationship building, and problem solving abilities. o Ability to read, analyze and interpret professional/legal/medical documents, policies and procedures, government regulations, legislative issues and legal documents. o Ability to guide and motivate others, promoting adaptability and inspiring strong organizational performance. o Knowledge and understanding of Federal Medicare program, Medicare Advantage Plans, Affordable Care Act (ACA/QHP), and insurance claims. o Sustain personal discipline to work remotely without direct supervision and maintain reliability and a commitment to meeting tight deadlines o Maintain knowledge of HIPAA, recognizing a commitment to privacy, security and confidentiality of all medical chart documentation. o Intermediate understanding of health care insurance claims practice and compliance. o Demonstrate proficiency in Microsoft Office (Word, Excel, PowerPoint) and electronic health record systems (i.e. Athena, Amazing Charts, EPIC, eClinical Works, or other similar systems).

  *PREFERRED QUALIFICATIONS *

• Education: Associate’s degree in accounting or healthcare.

• Licensure: No additional.
• Certification: o Professional Academy for Health Management (PAHM) certification. o Clinical Documentation Expert Outpatient (CDEO) from AAPC.
• Work Experience: No additional.
• Knowledge/Skills/Abilities: No additional.

*PHYSICAL REQUIREMENTS *

• Majority of time involves sitting or standing; occasional walking, bending, stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined; on site or remote.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

Job: *Health First Health Plans (Health Insurance)

Organization: *HF Administrative Plan Inc

Title: Lead Risk Adjustment Analyst - HFHP Risk Adjustment

Location: Florida - Brevard County-Rockledge

Requisition ID: 074771