Quality Coding Program Manager

Job not on LinkedIn

🔥 1 minute ago

🏄 California – Remote

🏄 California – Remote

💵 $100k - $150k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Program Manager

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Gold Coast Health Plan

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2011

At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

📋 Description

• Develop and maintain a Quality Coding work-plan and convene committees and workgroups to drive and oversee risk adjustment work • Implement and oversee quality coding initiatives and projects • Partner with internal teams and external vendors to monitor program and vendor performance and facilitate improvement activities • Ensure complete, accurate, timely, and compliant reporting of risk adjustment data in accordance with CMS requirements • Coordinate, develop, and analyze key indicators, performance data, and reporting tools for risk adjustment operations and quality coding programs • Define, design, implement, and maintain data files and data extracts for reporting needs • Maintain knowledge of applicable laws, regulations, and CMS guidance for risk adjustment, Medicare Advantage, and ACA/Exchange requirements • Deliver provider and staff education to facilitate clinical documentation improvement and improve performance and outcomes • Review and audit medical record documentation to validate diagnoses and ensure CMS Risk Adjustment compliance • Support CMS RADV audit readiness, including chart validation, mock audits, record retrieval, documentation reconciliation, and regulatory submissions • Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider, and vendor performance data • Partner with Finance to forecast risk adjustments and track coding-quality impact • Potential travel for auditing purposes • Perform other duties as assigned

🎯 Requirements

• California residency required; this position is open to California residents only • Bachelor’s degree in Health Information Management, Healthcare administration, Public Health or a related field • Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS) • 3–5 years of experience in medical coding, risk adjustment, HCC coding, coding audits, and provider education • Strong knowledge of CMS-HCC, HHS-HCC, RADV processes, ICD-10-CM, CPT, HCPCS, risk adjustment methodologies, and CMS rules for Medicare Advantage health plans • Experience developing and managing healthcare-related programs from ideation through execution in a highly matrixed environment • Experience in a Medicare Advantage health plan or managed care setting • Experience navigating electronic medical record (EMR/EHR) systems • Analytical, data management, problem-solving, critical-thinking, strategic-thinking, organization, time-management, prioritization, communication, and presentation skills • Ability to manage multiple projects and adapt to changing priorities and business needs • Ability to present complex information in a simplified, easy-to-understand manner • Technical aptitude to learn new data management and analysis tools or methodologies quickly • Proficiency with Microsoft Office Suite • Valid and current Driver's License, Auto Insurance, and professional licensure(s)