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   Current UPMC employees must apply in HR Direct

Senior Manager Clinical & Coding -Quality Assurance

Description

UPMC Health Plan is seeking an individual with a BSN and Coding Certification to fill a vacancy of a Senior Manager Clinical & Coding -Quality Assurance!

This position is remote within the continental US. 

This person will lead a team of 14 remote employees and direct and coordinate activities of workers engaged in audit activities related to diagnosis, CPT/HCPC, and HCC. Previous experience with HCC/Risk Adjustment experience & Medical Record Review is a must.  

Creates and implements review processes to address identified new risks. Responsible for the creation and maintenance of audit tools, business flows, policies and procedures and other auditing functions. Participates as a member of the management team in formulating, establishing, and maintaining department budgets, policies and procedures, quality assurance measurements, and a high-caliber team-oriented working environment. Creates goals and objectives to address the organization's mission, values, and standards of conduct. Monitors that standards of quality and production of work are met or exceed service requirements. Specifically, is responsible for quality review/monitoring of Health Plan Coding Specialist Staff/or external coding personnel. Performs auditing functions including monitoring, coding of diagnosis, reviewing medical record documentation and discharge summaries to determine if appropriate code was assigned to ensure Health Plan compliance with coding standards. Provides clinical and coding-related guidance and analysis to internal QA, F&A, Complaints & Grievances staff as needed. This position functions in a senior management role, with primary responsibility for the overall operation of the Quality Assurance & Operational Integrity Coding review team. Works with internal and external customers, senior management, UPMCHS and UPMCHP department representatives, and vendors as necessary.


Responsibilities:

  • Directs and coordinates activities of auditors engaged in audits of HCC and other coding activities, including:
  • Review the coding of diagnoses and verify the proper ICD-9-CM codes were assigned by the HCC Coding Specialist.
  • Ensure that all codes are documented for the assignment of a valid and accurate Hierarchical Condition Category (HCC).
  • Monitor the assignment of the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology and pathology.
  • Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.
  • Determine diagnoses that were treated, monitored and evaluated and procedures done during the episode of care to validate that the appropriate codes were assigned by the HCC Coding Specialist.
  • Oversee monthly quality reviews of implemented policies
  • Ensures that all turnaround times and quality measurements are met.
  • Communicates/coordinates activities with staff and customers to ensure delivery and completion of assignments, projects, and other performance commitments.
  • Coordinates ICD 10 implementation and follow through for QA/F&A department.
  • Recruits and manages staff that performs audit activities.
  • Assist with the National Risk Adjustment reviews and audits
  • Analyzes, evaluates, and presents information concerning factors, such as business scenarios, production capabilities, and design and development of department workflows.
  • Identify high risk HCC diagnosis codes, oversee review processes and distribution of findings to customers
  • Manages coding audit staff, including the completion of staff performance evaluations.
  • Ensures ongoing assessment of team needs related to staffing, audit tools and training.
  • Identifies critical business objectives, develops and operationalizes business plans to support critical objectives.
  • Working with PACE vendor on quarterly HCC reviews, update review processes, audits, summaries and meeting as need with external reviewer.
  • Serves as an instructor and discussion leader.
  • Creates inventory audit maintenance and reduction plans.

 

Qualifications

  • Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) related to medical record documentation or a certified coding program such as American Academy of Professional Coders (AAPC) required.
  • Due to the role's responsibilities at this time, we will not be considering any candidates without a Bachelors in Nursing (BSN).
  • Seven (7) years of progressive/leadership experience in clinical auditing/coding/or related within a health care or health insurance setting required.
  • Two (2) years of directly related experience in a Supervisor or Manager capacity is  required
  • Experience and knowledge of reimbursement and clinical/procedural coding, claims processing, multiple lines of business, auditing and benefit plans and design.
  • Extensive knowledge of ICD-9/ICD 10 and CPT classifications and coding of diagnoses and procedures is required.
  • In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.
  • The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential.
  • Excellent written and verbal communication skills are essential. Proficiency in computer skills required for coding.
  • Detail oriented individual with excellent organizational skills High degree of oral and written communication skills.
  • Strong leadership skills and abilities, and strong independent decision-making skills.
  • Expert process and project management, negotiation, and analytical skills.
  • Excellent organizational, interpersonal and conflict management skills.
  • Proficiency in Microsoft office software applications.


Licensure, Certifications, and Clearances:

  • Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct