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Reporting to the Senior Manager of Medicaid Risk Adjustment, the Market Manager of Medicaid Risk Adjustment will work closely with cross-functional leadership across the Medicaid business to establish and champion a local market culture committed to revenue integrity excellence.
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Applies advanced knowledge of CMS star rating, Vizient, and US News and World Report risk-adjustment systems to identify clinical documentation improvement opportunities. Knowledge of Vizient, Premier, US News and World Report, CMS star rating or similar risk-adjustment methodologies highly preferred.
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The Clinical Documentation Integrity (CDI) Second Level Reviewer performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures to reflect severity of illness, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care.
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Knowledge of the Healthcare industry including physician practices, market access, insurance, managed care, organized delivery systems, STARs/HEDIS, Value based care and risk adjustment models.
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Investigate and/or resolve billing, coding and medical necessity compliance inquiries, complaints, and problems as directed by the VP of Quality & Risk Adjustment. This individual will, under general direction from the Senior Director of Quality & Risk Adjustment, perform and/or coordinate audits in accordance with official coding guidelines as set forth by CMS regulations, and other applicable federal and/or state guidelines (i.e., AHIMA, ACOG, CMS); and client-specific policies.
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CSI Companies Coding and Clinical Data Integrity Practice is immediately seeking a Risk Adjustment Coding Project Manager (Remote) for a contract position with one of our clients in the payer space.
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Your primary objective will be to assess the overall health and well-being of member beneficiaries to ensure accurate and comprehensive risk adjustment coding, leading to greater value-based care.
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Knowledge of HEDIS and Risk Adjustment Coding is helpful. License and certifications:Certification Preferred Risk Adjustment Coding, Quality, Project Management. Coordination and Planning Coordinate the planning, and completion of projects and complex tasks needed to ensure the Guidewell Sanitas PHSO's successful performance in value-based arrangements Ensures all Affiliate providers are onboarded and understand the expectations, and resources available for success within the PHSO.
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Manage end to end process from Risk Adjustment to claim submission. A minimum of 10 years' experience in progressively responsible administrative or management-related positions required; preferably within a payor or risk-based primary health care environment.
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Assists in the development of risk adjustment projections for both the Commercial and Medicare product line. Essential Job Functions:Assists in the assessment of feasibility, anti-selection risk, marketability, alternative product options, existing product options, improvements, market needs, configuration issues, and portfolio placement of new products.
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Must meet compliance with Centers for Medicare & Medicaid Services’ (CMS) risk adjustment guidelines, Association of Certified Documentation Improvement Specialists (ACDIS), American Association of Professional Coders (AAPC) and the American Health Information Management Associations (AHIMA) coding and documentation guidelines.
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Experience with Medicare Advantage STARS or Risk Adjustment. Works to develop and deliver high impact interventions, supporting content development and practice transformation embedded capabilities to significantly improve provider performance that drive cost of care and improve HEDIS/Stars where applicable.
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As a delegated full-risk company, ensuring we obtain all potential premium dollars from our payor partners is essential. Risk-Based Service fund payment experience required. The Vice President, Revenue Management is responsible for optimizing revenue from our payor (health plan) partners through contracting and contract management as well as end to end revenue cycle management.
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Support Creation and Maintain Risk adjustment / Clinical Documentation Curriculum ( consistent with CMS guidelines). Experience with Risk adjustment and CMS regulation related to Coding and Documentation accuracy guidelines.
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Operating in the alternative investment space, our goals are capitalpreservation and superior risk adjustment returns that are traditionallyuncorrelated with the market. Our company is led by experienced real estate finance professionals with backgrounds in residential mortgages, commercial mortgages, structured finance, and special servicing.
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risk adjustment jobs in Miami, FL
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