VP Quality and Clinical Documentation

Company: ConcertoHealth
Location: Aliso Viejo
Posted on: March 22, 2020

Job Description:

The VP, Quality and Clinical Documentation leads strategy development and execution for CMS and State Quality and Risk Adjustment programs, initiatives, and projects to meet the stated organizational goals under the direction of the SVP, Clinical Operations. In addition, the VP will serve as the organizational - internal and external facing- risk adjustment subject matter expert and will lead the Member Engagement & Encounter Facilitation team and oversee the various programs and activities carried out by the team. The VP will also oversee Encounter Data/Claims submission processes and appropriate reconciliations.The VP is responsible for ensuring that all Risk Adjustment and Quality programs and initiatives are carried out in manner that is compliant and consistent with Centers for Medicare and Medicaid Services (CMS) and State and federal regulatory requirements.ESSENTIAL DUTIES AND RESPONSIBILITIESRisk AdjustmentServe as organizational subject matter expert for risk adjustment including the end-to-end process, points of failure, opportunities to optimize and appropriate management of the process across the continuumDevelop overall Risk Adjustment strategy for the organization, taking compliance, strategic goals and imperatives and nuances of markets and client and vendor relationships into accountServe as primary point of contact for external stakeholders for insight and strategy for risk adjustment activities and process managementPartner with health plans to ensure the end-to-end process is optimized between the hand-offs from Concerto and community providers through the encounter / claims process through CMS data submission and return filesEnsure proper capture, documentation, and transmission of charts and codes related to risk adjustment to payer partnersEnsure that all professional and facility claims and encounter data from all care settings are transmitted to the appropriate payers and subsequently to CMSLead efforts to track, aggregate, and report on risk adjustment data and performanceTranslate all data to action (program design, etc) and business implications underpinned by the financial implications of the risk adjustment dataOversee coding team staff and operations responsible for clinical documentation review and provider education efforts and ensure successful execution of assigned tasks and responsibilitiesDevelop and implement clinical documentation review and coding programs to drive improved data capture and more efficient operationsCoordinate all chart review and audit requests from payer partnersDevelop and implement provider engagement and education programs related to clinical documentation and codingLead implementation of software and IT solutions related to quality data, analytics, and forecastingImplement various programs, including in-market and in-home designed to ensure proper evaluation and documentation of members and their health conditionsCollaborate with medical management and clinical teams to drive key initiativesQualityServe as primary point of contact for HEDIS/Stars activities across the organizationLead efforts to track, aggregate, and report on quality data and performance including STARS/HEDIS and state specific programsDevelop provider and member programs and initiatives to drive performance in the areas of STARS/HEDISCoordinate STARS/HEDIS activities with internal departments and staff, including clinical staff, to successfully execute initiatives, activities, and programs and to help ensure achievement of desired resultsWork with health plan partners to facilitate receipt of gap dataEnsure proper transmission of charts, claims, and supplemental dataLead implementation of software and IT solutions related to quality data, analytics, and forecastingDevelop education and training programs for staff related to quality including STARS/HEDISCoordinate with health plan partners to align quality related programs with existing plan programs and to implement new/improved programs as appropriateMember Engagement & Encounter FacilitationLead Member Engagement & Encounter Facilitation team responsible for contacting member and providers in order to facilitate member visits and/or completion of exams/testsDrive efficient operations of team through implementation of streamlined processes and procedures, development of improved reporting and productivity tracking, and utilization of automated and other IT solutionsDevelop scripting, training guides, and other tools for use by staff to help achieve team and associated corporate goalsEnsure that team members serve as advocates for members' needs and help drive improved and proper member care and treatmentCoordinate with health plan partners on data sharing, reporting, and program elements related to outreach activities--QUALIFICATIONSMBA Degree or equivalent work experience strongly preferred8-10 years of experience in the healthcare industryAt least 5 years of experience managing Quality and Risk Adjustment teams and initiativesExperience developing and implementing new Quality and clinical documentation/Risk Adjustment programsStrategic thinking and operational leadershipAbility to communicate effectively with both internal and external staffExperience with developing, implementing, and managing projectsProven leadership skills in physician practice relationships, including influencing, efficiency, collaboration, and openness with a focus on resultsExperience working with and implementing vendor solutionsAbility to perform ad-hoc analysis and reports as requiredStrong written and verbal communication skills

Keywords: ConcertoHealth, Aliso Viejo , VP Quality and Clinical Documentation, Executive , Aliso Viejo, California