Job Description:
Responsible to manage a team of clinicians and/or medical coders charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
- Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
- Oversees Complex Clinical Audit operations to ensure accuracy, efficiency, and compliance with coding standards and payer requirements, while driving performance, resource planning, and process improvements, serves as the key liaison across clinical, coding, and compliance teams, monitors audit trends and risks, ensures audit readiness, leverages data analytics for decision-making, and champions automation to streamline workflows and enhance operational outcomes.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.
Qualifications:
- Requires current, active, unrestricted Registered Nurse license, either Philippines in applicable state(s) or territory of the United States
- One or more of the following certifications are preferred: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or Inpatient Coding Credential such as CCS or CIC
- Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and/or a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG or combined healthcare experience.
- Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement experience preferred.
- Minimum of 2 years hospital experience and/or several years of inpatient hospital coding experience.
- Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
- Capability build experience, expansion and transition of programs
- Strong people management and accountable leadership, stakeholder management, growth mindset, execution-bias, amongst others
