Responsible for directing foundational and strategic compliance responsibilities with consistent excellence that support the team and management. Will focus on provider audits by performing a review of documentation to ensure risk mitigation and compliance with the Centers for Medicare & Medicaid Services (CMS), ICD-10-CM coding guidelines, and medical record documentation requirements that will be used in developing, reviewing, and/or presenting documentation & coding training materials where appropriate.
Primary duties with expert skill level and tasks with the most advanced complexity and broad/enterprise scale may include, but are not limited to:
- Directs projects, initiatives, regulatory sanctions, executive-sponsored initiatives, regulatory audits or exams, internal audits, accreditations, on-site reviews, risk assessments; audit planning, conducting mock audits, conducting audit training, managing audit evidence preparation, assessing audit preparedness.
- Leads compliance monitoring to identify process gaps, validate compliance levels, map processes, draft corrective actions/remediation plans, oversee implementation of corrective actions, prepare reports/presentations.
- Leads complex investigations and documents findings.
- Develops strategic plans, makes recommendations to leadership; designs/implements annual compliance plan.
- Review of Medicare Advantage member medical record documentation
- Serve as coding subject matter expert to internal and external stakeholders
- Create/Present educational material on documentation & coding for Medicare Risk Adjustment purposes
- Develop strong relationships with key leaders to identify and address compliance risks and failures and manage action plans designed to fully mitigate risk(s).
- Requires a BA/BS and minimum of 8 years health care, regulatory, ethics, compliance or privacy experience; or any combination of education and experience, which would provide an equivalent background.
- Strong leadership/managerial skills and ability to motivate/coach other staff strongly preferred. Ability to travel may be required. MS/MBA/JD or professional designation preferred.
- Coding certification ( e.g., Certified Coding Associate or Certified Professional Coder) from an accredited source ( e.g., American Health Information Management Association or American Academy of Professional Coders) preferred.
- Certified Risk Adjustment Coder – a plus.
- CDEO certification and/or RN experience strongly preferred.
- 5+ years of experience of relevant coding and/or medical record audit experience. (Audit experience can be in a physician’s office, hospital or insurance office setting.)
- Experience developing educational materials is preferred.
- Medicare Risk Adjustment experience preferred.
- IRR (Inter-Rater Reliability) experience/background preferred.
- Proficient with MS Office applications: Word, PowerPoint, Excel preferred.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.