Type of Employment: Full Time
Department: Clinical Process Outsourcing (CPO)
Reports To: Chief Revenue Officer
Location: Nashville, TN OR Remote
Travel: 25-50% (Seasonal, based on account needs)
The Senior Director, Risk Adjustment Coding and Client Services is responsible for providing expertise in clinical coding practices and risk adjustment coding operations for health plan, provider and third-party vendor clients. He/She will interface with operational and clinical leadership to ensure all policies, procedures, products and services are compliant and in line with all regulatory requirements. He/She will serve as the liaison to Shearwater clients and the Philippines coding team, providing expert guidance related to risk adjustment operations and clinical coding practices. The Sr. Director will also collaborate with clients and the Shearwater team to apply the national coding guidelines to all work outputs, delivering compliant, quality outcomes for all client-facing work. He/She will lead efforts to identify operational and clinical best practices as they relate to compliant, complete and appropriate coding for risk adjustment purposes. He/She will also coordinate implementation of programs designed to ensure all diagnosed codes and conditions are properly supported by appropriate documentation in the patient chart.
• Maintain Shearwater’s internal coding policies, procedures and other materials to ensure the highest-level quality, productivity, accuracy and completeness for risk adjustment coding.
• Lead efforts to develop provider education, engagement, and clinical documentation improvement strategies.
• Perform Hierarchical Condition Category (HCC) mapping, modeling, and maintain Shearwater’s best-in-class risk adjustment coding solutions.
• Support clients in developing best-in-class coding programs and operating models in the instances where gaps and deficiencies have been identified.
• Support Sales and Account Management, serving as a Subject Matter Expert to add credibility to Shearwater’s products and services.
• Lead Shearwater’s client-specific retrospective and prospective strategies to ensure complete, consistent coding practices with health plan and provider operations.
• Facilitate concurrent chart reviews and assessments to identify trends and opportunities for increased efficiencies and improved accuracy.
• Identify opportunities to maximize data and improve efficiencies and integration between multiple data sources, including provider Electronic Medical Record (EMR), Health Information Exchange (HIE), and claims warehouses.
• Play a key role in the documentation of client specific quality assurance programs, operational workflows and report outputs.
• Partner with leadership to identify industry partners as they relate to coding platforms, chart retrieval technology, NLP, CAC and AI.
• Facilitate the creation and implementation of measurable improvement strategies in the areas of physician clinical documentation, medical record coding, and submission of data, specifically for integrated care delivery systems, at-risk medical groups, Independent Practice Associations(IPA) and Accountable Care Organizations (ACO) and other value-based provider programs.
• Identify and apply chart retrieval, storage, and integration best practices to maximize risk adjustment activities and support quality and medical management initiatives.
• Maintain internal and develop client-facing compliance, Risk Adjustment Data Validation (RADV) and overpayment recovery strategies, supporting claims integrity, and consistent capture of persistent chronic conditions.
• Conduct cost-benefit analysis of internal vs. external coding programs, including vendor quality oversight and development of service level agreement (SLA) language.
• Create and deliver a wide range of coding and billing education modules, both onsite and virtually.
• Prepare and deliver results to chart review findings, highlighting opportunities for clinical and operational improvement, trends in provider coding patterns, and reconciliation of patient clinical information.
• Ensure member encounter data is being accurately coded and all diagnosis codes are captured.
• Provide measurable, actionable solutions to provider and health plan clients that will result in improved accuracy for documentation and coding practices.
• Responsible for collaborating with Sales, Account Management and the Philippines operations for project planning and execution of client projects for projects directly managed.
• Develop recommendations for the client in context of the overall scope of work and contract details.
• Provide guidance and information, when requested, as an internal resource and subject matter expert
• Apply subject matter expertise to expand upon or create additional products, services and project tools to enhance the client satisfaction and deliverables while increasing profitability.
• Interact with the client’s decision-makers, working cooperatively to achieve the project goals.
• Assess status of overall project initiatives and report key results to Account Manager and Executive Sponsor.
• Prepare routine and ad hoc reports by obtaining, compiling, analyzing, and summarizing data from various sources.
• Provide industry guidance to staff within the Risk Adjustment Coding Practices.
• Demonstrate ability to produce high-quality results in personal work product by continuously upgrading one’s own skills and expertise.
Required Experience and Education
• Bachelor’s degree is required with a concentration in a healthcare-related field.
• Must currently have AAPC Certification:
o CPC, CPMA, CRC
o AHIMA Approved ICD-10 CM/PCS Trainer, ICD-10 Ambassador
o CDIP (Clinical Documentation Improvement Practitioner) certification is preferred but not required.
• Ability to read and analyze all information in a patient’s health record.
• Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology).
• Extensive knowledge of and experience with coding concepts, guidelines, and clinical terminology.
• Knowledge of healthcare regulations, including reimbursement and documentation requirements.
• Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements, including clinical documentation, of what constitutes an acceptable risk adjustable code.
• Expertise with ICD-9-CM and ICD-10-CM Official Coding Guidelines.
• Extensive knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with HCC methodology and risk adjustable codes, establishing and meeting medical necessity criteria; including response to treatments, interventions, and outcomes; complete and accurate patient treatment plan.
• Knowledge and understanding of official physician Evaluation and Management (E&M) guidelines and documentation requirements in support of proper E&M assignment and establishment of medical necessity.
• Knowledge of the CMS Part C environment in relation to health plans, insurers, providers, vendors and facilities, and CMS Part C program requirements including Part C reporting. Understand all CMS Medicare and Medicaid and Part C & D requirements including manuals, review guides, and Code of Federal Regulations.
• Perform independently, prioritize and manage multiple tasks effectively, organize work flows, adhere to timelines, attain goals, and function in a complex, fast-paced work environment.
• Ability to interact with internal and external customers at all management levels.
• Project management and/or consulting experience a plus.
• Strong problem-solving ability and a customer-centric focus.
• Be team focused with an attitude of group achievement as the primary goal.
• Highly organized with a strong attention to detail.
• Ability to travel 50% of the time.
• Ability to work in a virtual office and virtual teaming experience.
• Effective collaboration skills and experience.
• Microsoft Office proficiency.
• Strong oral and written communication skills, including presentation skills.