Lead, Revenue Integrity & Coding Support

Description The Revenue Integrity & Coding Support Lead identifies and analyzes Clinical Documentation process and medical documentation to ensure coding is accurate and properly supported by clinical documentation within the health record. This role organizes and directs documentation and coding education programs. The role assumes broad responsibility and provides recommendations to ensure compliance with reporting requirements. This role works takes an organizational focus and will need to be familiar with payer and regulatory guidelines across multiple jurisdictions. With leadership, develops and implements procedures and cost-effective approaches to minimize the organization's risks related to medical documentation and coding. This role will oversee quality control audits, the communication of audit findings and provision of education related to regulatory requirements for billing to clinical providers, coding, billing and other Care Delivery Organization associates. The Revenue Integrity & Coding Support Lead works on problems of diverse scope and complexity ranging from moderate to substantial. This role requires a thorough understanding of the relationship between codes and revenue in the reimbursement process, specifically how revenue is generated from ICD-10CM, ICD-10PCS, CPT and HCPCS codes. The Lead, Revenue Integrity and Coding Support must maintain current knowledge of regulatory changes that impact documentation, coding and billing practices as well as expertise in clinical operations, coding and billing office workflows. The Lead role assesses and communicates information regarding medical documentation and coding best practices across the organization and will need to build relationships with leaders and identified stakeholders. Advises executives to develop functional strategies on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision. The Revenue Integrity and Coding Support lead contributes to the organization’s overall risk reduction by increasing the accuracy of medical documentation and coding through education, and by ensuring correct claims payment. The Lead role uses independent judgment requiring analysis of variable factors and determining the best course of action. The successful candidate will be detail-oriented, with proven ability to effectively manage time, delegate, see tasks and projects through to completion, organize competing priorities and effectively address complex, urgent issues as they arise. Responsibilities Actual role function examples: Decisions may also be related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with managers and other leaders across the department. Design, plan, organize, and direct audit programs, specifically around requirements based upon the following: risk adjustment, professional services documentation and coding, National Coverage Determination (NCD), Local Coverage Determination (LCD), Recovery Audit Contractor (RAC) and Additional Documentation Requests (ADR) as well as other process and policy documentation requirements and improvements. The Lead is responsible for organizing and managing the daily operations of Revenue Integrity department. Design, plan, organize, and direct orientation and education programs for assigned employees in the Care Delivery Organization, specifically around requirements based upon the following: risk adjustment, Medicare Guidelines, professional services documentation and coding, National Coverage Determination (NCD), Local Coverage Determination (LCD), Recovery Audit Contractor (RAC) and Additional Documentation Requests (ADR) as well as other process and policy documentation requirements and improvements. Responsible for serving as a principal liaison regarding payer guidelines, explaining regulatory requirements, and overseeing the accountability process for Revenue Integrity. Serves as Subject Matter Expert to leadership on issues related to Revenue Integrity and CMS payer reimbursement guidelines. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management. Takes responsibility for working with coding managers and other leaders to develop processes to ensure accurate and appropriate documentation to support coding and billing efforts as necessary. Work at home; may require 30% to 50% travel as needed. Must live in market - TX, FL, MO, KS, NC, SC, NV, LA Required Qualifications Bachelor’s degree in business administration, healthcare administration, other related healthcare or if have direct Revenue Integrity and Coding Leader experience obtain BA Degree within 12 months of employment. AAPC Certified as a CPC (certified professional coder) or AHIMA CCS-P in place of CPC CPMA (Certified Professional Auditor) or agree to obtain within 6 Months of Employment 8 or years of experience related to auditing and/or coding 5 or more years of management experience in a matrix environment In-depth knowledge of Medicare/Medicaid regulations, including billing, coding and documentation requirements. Understanding of the application of authoritative guidance to the interpretation and analysis of documentation, coding, and queries. Experienced leading meetings and presenting material to broad audiences Demonstrated record of achieving performance goals and objectives Demonstrated analytical skills by integrating complex information, while balancing tactical and strategic initiatives Demonstrated ability to produce desired results by leveraging resources, managing resources and relationships effectively, and defining and communicating clear expectations Demonstrated strong interpersonal, proactive communication and leadership skills including a willingness to consistently provide superior customer service, the ability to react appropriately under pressure, and the ability to apply good judgment in ambiguous situations Ability to build and maintain effective relationships with associates, consumers and internal and external business and community partners Able to determine the needed approach, resources, and goals to solve problems Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, Excel, etc. Must work with and respect highly confidential information Experience in a fast paced, metric driven operational setting Ability to analyze large amounts of data to create and present reporting This role is part of Humana's Driver safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100/300/100 limits Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications Master’s degree in business administration, healthcare administration or other related healthcare degree AAPC certification: CRC (certified risk coder) Experience with eCW Knowledge of Microsoft Office 365, Teams Experience managing remote employees Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website. Scheduled Weekly Hours 40