Risk Adjustment Data Validation Supervisor

Regular Exempt GENERAL DESCRIPTION: The Risk Adjustment Data Validation Supervisor is responsible for ensuring that scheduled internal and external audits of the contracted independent contractors and suppliers are conducted at the designated time. Monitors the implementation of the clinical coding audit work plan to mitigate risks, enhance efficiency in retrieving clinical information, and reduce negative findings in Risk Adjustment Data Validation (RADV) audits. Maintains a record of audited suppliers and recommends appropriate action plans for improvement. ESSENTIAL FUNCTIONS:
• Responsible for reviewing the performance of clinical coding audits, primarily focused on specific verifications and validations of RADV, evaluating the results to recommend or design initiatives needed to improve or correct the identified findings.
• Responsible for monitoring processes related to the RADV Business Rule implementation at the clearinghouse level.
• Responsible for documenting and implementing standard operating procedures (SOP) for the Office of Inspector General (OIG) Toolkit and the High-Risk Mitigation Tool to reduce risks associated with non-validated diagnoses.
• Responsible for the implementation of risk mitigation initiatives to prevent, detect, and correct patterns that could represent risk in RADV audits.
• Responsible for the documentation and implementation of SOPs for the RADV appeal tool according to the Final Rule requirements.
• Perform quality audits and establish corrective action plans based on the results, if applicable, and prepare the final report, including interventions and recommendations to management.
• Accountable for building medical providers, Independent Physician Association (IPA), and billing representatives of medical offices to improve their coding, documentation, validation of diagnoses, and other good practices.
• Handles telephone communication in response to audits and referrals related to identified areas of opportunity.
• Keep the documentation of various audits up to date, including the identified findings, corrective action plans, and interventions implemented.
• Prepares and submits audit reports to management based on the established work plan and recommendations. ADDITIONAL FUNCTIONS:
• Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM

QUALIFICATIONS:
Education and

Experience:
Bachelor’s Degree in Health Services Administration, Health Sciences, or related areas. At least three (3) years of experience performing similar functions related to the adjudication and payment of claims. At least one (1) year of experience supervising staff. "Proven experience may be replaced by previously established requirements." Certifications / Licenses: Certification in Clinical Coding, such as Certified Coding Associate (CCA), Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician (CCS-P) is preferable. Other: Knowledge in Medical Coding systems using the following classification systems: ICD-10-CM, CPT 4, HCPCS, as well as the use of essential modifiers. Knowledge of legal aspects of the Medical Record. Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal) “We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”