Senior Manager, Health Care Quality Management

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Position Summary

Experienced / career level position responsible for overseeing quality review audits of medical records coded by internal team (CDQA and Sr Analyst CDQA) to ensure the ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.

In this position you will have the opportunity to demonstrate proficiency in the following :

• Proven ability to support coding judgment and decisions using industry standard evidence and tools.
• Ability to confidently speak to such evidence across stakeholders with varying knowledge and clinical expertise in either written or verbal forms including communication with clinical or coding staff, federal regulators and vendor coding resources.
• Manages team and leads dispute resolution.
• Provides education to internal staff based on audit findings; provides general education on ICD codes as appropriate.
• Effectively communicates the audit process and results to appropriate departments and management.
• Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
• Identifies and recommends opportunities for process improvements so that productivity and quality goals are met or exceeded and operational efficiency with final accuracy is achieved.
• Ability to work independently as well as in a cross functional role within other teams for collaboration on best practices.
• Adhere to stringent timelines consistent with project deadlines and directives.
• Must possess high level of dependability and is accountable to team to ensure coding accuracy and production standards is met.
• Monitors own work to help ensure quality.
• Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law.
• Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
• Medical record auditing skills and abstraction expertise.
• Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
• Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
• Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and / or facility setting.
• Thorough knowledge of coding guidelines and regulations to meet compliance requirements.
• In depth knowledge of medical terminology and anatomy for all body systems.
• Understand the audit process for risk adjustment models.
• Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers.
• Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
• Apply AHA Coding Clinic guidance to identify and resolve coding issues.
• Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations.
• Performs other related duties as required.

Required Qualifications

• 3+ years management experience required.
• Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
• Experience with International Classification of Disease (ICD) codes required.
• Minimum of 5 years recent and related experience in medical record documentation review, diagnosis coding, and / or auditing.
• Experience with Medicare and / or Commercial and / or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required and maintain CEU’s.

Preferred Qualifications

• Excellent analytical and problem-solving skills.
• Superior communication, organizational, and interpersonal skills

Education

• BA / BS or equivalent professional work experience.
• Completion of AAPC / AHIMA training program for core credential (CPC, CCS-P) with associated work history / on the job experience equal to approximately 3 years for CPC.

Pay Range

The typical pay range for this role is :

$67,900.00 - $149,300.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

This position also includes an award target in the company’s equity award program.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.