Senior Manager, Program Integrity (CPC, RHIT or RHIA required)

📋 Description

• • Lead and direct a team of medical record coding auditors, ensuring the successful achievement of departmental goals and strategic objectives.
• • Drive the implementation of optimization opportunities for both prepay and post-pay medical record auditing procedures, focusing on process improvements to enhance auditing timeliness and quality outcomes.
• • Oversee and maintain comprehensive supporting business and regulatory processes and documentation, ensuring they remain current and compliant.
• • Proactively track and communicate production issues and escalations, coordinating effectively to ensure proper follow-up and resolution.
• • Manage project plans for all projects involving configuration, ensuring timely completion and escalating any potential deviations from established timeframes.
• • Spearhead new product and new vendor implementations, guaranteeing both timeliness and high quality throughout the process.
• • Develop and implement robust ticket controls, ensuring appropriate communication and necessary approvals are secured prior to system implementation.
• • Actively participate in strategic planning initiatives and translate strategic goals into actionable implementation plans.
• • Analyze and determine appropriate reimbursements and/or modifications to Coding review guidelines in close partnership with medical directors and clinical staff.
• • Contribute significantly to new business readiness by defining and implementing comprehensive coding audit requirements.
• • Stay abreast of the latest industry issues, trends, and changes in laws and regulations governing medical record coding and documentation by reviewing bulletins, newsletters, periodicals, and attending relevant workshops.
• • Develop and update procedures to maintain high standards for correct medical record auditing and coding practices, thereby minimizing the risk of fraud, waste, abuse, and error.
• • Provide expert-level consultation and guidance on analytic software and coding, leveraging deep knowledge of coding, reimbursement, and policy.
• • Oversee the documentation, testing, and promotion of code editing solutions, adhering strictly to established departmental change management processes.
• • Lead research and analysis of data related to code edits, drawing informed conclusions to resolve issues and participating in provider calls to discuss findings.
• • Consult on the refinement of predictive analytic modeling to effectively drive down false positive rates.
• • Monitor and manage applicable departmental expenses, ensuring alignment with the current year's budget.
• • Generate and maintain reportable Quality Assurance Initiative (QAI) savings for the department, reporting combined annual savings derived from vendor and line of business performance.
• • Provide expert oversight and in-depth knowledge of reimbursement methodologies, including Ambulatory Procedural Coding (APC), Diagnosis Related Groupers (DRG), Outpatient Prospective Payment System (OPPS), and professional claim reimbursement.
• • Take full responsibility for the hiring, coaching, development, and performance management of staff, fostering a high-performing team environment.
• • Perform any other job duties as requested to support departmental and organizational objectives.
• • Ensure adherence to all regulatory reporting and compliance requirements.
• • Apply advanced computer skills and proficiency in systems like Facets, demonstrating a strong understanding of medical terminology.
• • Utilize Microsoft Suite (Word, Excel, Access) effectively for reporting, analysis, and communication.
• • Employ a high level of programming and systems development knowledge to identify and solve complex business problems.
• • Demonstrate a proven ability to define and manage a portfolio of initiatives, encompassing business requirements gathering, scope definition, staffing, application configuration, testing strategies, training development, documentation, reporting strategies, and change management.
• • Apply strong critical thinking and problem-solving skills with meticulous attention to detail.
• • Foster a collaborative workplace culture and cultivate strong partnerships across departments.
• • Drive execution of strategic initiatives and influence stakeholders to achieve desired outcomes.
• • Pursue personal excellence and a deep understanding of the business operations.
• • Ensure the team operates with a high level of professionalism and ethical conduct.
• • Manage team workload and priorities effectively to meet deadlines and achieve performance targets.