This key role will provide support in the planning, evaluation, project management and performance that support the mandated CMS RADV audits as required for both ACA and MA segments. This position will require the candidate possess analytical and strategic thinking skills typically attained from experience with interpreting CMS regulations and participation in the RADV audit process.
Produce oversight for and coordination of various stakeholder teams, investigate and monitor regulations and changing CMS guidance, and ensure updates are incorporated into protocols for maintaining CMS compliance and continuous process improvements.
Develop statistical reporting, weekly metrics, detailed project plans and schedules. Support goals and objectives and identifies and communicates risks to leadership.
Monitor audit status for any significant deviations in timeline that may produce risk.
Identify opportunities to support strategy development through close collaboration and thorough analysis with various departments such as Strategy, Data and Analytics teams client Claims and Enrollment teams, and external vendors for project execution, problem solving and continuous process improvements.
Represent leadership staff at meetings in their absence
Assist with the development and delivery of business process design documentation and improvement methodologies.
Possess and maintain a comprehensive understanding and knowledge of company business, products, programs, organizational structure, and basic research principles/methodologies.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS:
Bachelor's degree in Business Administration, Economics, Health Care, Information Systems, Statistics or a related field. Master's degree preferred. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
Five (5+) years in health care field which includes experience in Risk Adjustment, Healthcare Policy, Compliance and/or Audit/Vendor Administration. Successful completion of a coding license or certificates; Credentialed Coder (CPC, CCS, CRC, CPMA), Clinical Documentation Specialist (CDIP, CCDS), or Licensed as a Registered Nurse. 3-5 years RADV audit experience in health plan operations.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Extensive knowledge of RADV audits and Risk Adjustment.
Strong communication skills are required to understand, interpret, and communicate ideas.
Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc.).
High comfort level with large data sets, data modeling and interpretation preferred.
Strong analytical, organizational, planning, and problem solving skills.
Ability to effectively interface with employees at all levels.
Other related skills and/or abilities may be required to perform this job.
Experience executing in a fast-paced environment with tight deadlines.
Administer and adhere to corporate and departmental policies, practices and procedures.
Ability to plan, organize, control and direct audits while exercising high ethical standards and good judgement.
Excellent quantitative skills and ability to interpret data from multiple sources; ability to synthesize complex data, information and reports into clear and simple reports.
Ability to lead and contribute to related projects.
Leadership and analytical experience required with demonstrated experience in operational analysis, data analysis, and problem resolution functions.
Provide expertise in analytical methodology (including data analysis) used to facilitate data driven decision making, including the collection and monitoring of metrics used to assess, prioritize and select improvement paths
Ability to work closely with the technical support team in understanding and resolving systems issues.
Work is performed in an office setting with no unusual hazards.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued, and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.