Director, Risk Adjustment & Quality

About the Position:

The position is based in Nashville, TN.

The Director, Risk Adjustment Coding and Quality position supports our growth globally by helping U.S. health insurers overcome the challenges of the nursing shortage and workflow efficiency. It focuses on serving existing customers success in coordination with our U.S. based Account Managers and the ability to grow our presence with the client. It will also have a strong emphasis on contributing to a diligent discovery process with new clients, clinical input for implementation plans, and coordination with our Philippines operations team to ensure efficient high-quality work. Because we are a versatile, fast-growing company, the position will also have the opportunity to support new product development and the development of new international relationships.

As the Director of Risk Adjustment & Quality you will:

  • Act as the risk adjustment coding and quality subject matter expert.
  • Be an active participant and support for the risk adjustment and quality leadership and production staff.
  • Support and assist in implementation of new risk adjustment and payer quality programs.
  • Oversee risk adjustment coding and quality staff, and peer review nurse qualification standards and staff selection.
  • Align business and clinical objectives related to risk adjustment and quality workflows.
  • Provide education and training based on gaps identified in clinical knowledge and risk adjustment and quality in compliance with industry accepted best practices.
  • Lead role in monitoring performance improvement.
  • Participate and chair committees aligned with risk adjustment and quality.
  • Provides guidance for programs involving population health.
  • Provides clinical and industry thought leadership for marketing new opportunities.
  • Participates in the discovery, evaluation, and solutioning of new clinical services.
  • Addresses client escalations regarding relevant workflows.
  • Participates in key client quarterly business reviews as clinical leadership representative.
  • Report directly to the SVP, Clinical Operations

About You:

You have…

  • Bachelor’s degree is required in a healthcare-related field
  • Must have current AAPC Certification:
    • CRC, CPMA, CPC
    • AHIMA Approved ICD-10 CM/PCS Trainer, ICD-10 Ambassador
  • 3-5 years of leadership experience
  • Familiarity with MS-DRG’s and the Inpatient Prospective Payment System (IPPS), Including new CMS guideline of key elements including clinical documentation, of what constitutes an acceptable risk adjustment code.
  • 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.
  • Experience in designing effective value-based care models, protocols, and clinical training to decrease inappropriate utilization and/or enhance quality of outcomes
  • Demonstrated commitment to patient-centered model of care delivery with proven quality management/improvement record
  • Strong problem-solving ability and a customer-centric focus.
  • Be team focused with an attitude of group achievement as the primary goal.
  • Ability to travel domestically and/or internationally at least 33% of expected work hours

It would be a bonus if you….

  • Have a master’s degree in business administration, healthcare, and/or nursing
  • Have an active Registered Nurse licensure.
  • Have a CDIP (Clinical Documentation Improvement Practitioner) certification
  • Have ever worked in a position as a liaison between healthcare entities or teams
  • Have worked with remote teams
  • Have experience working with team members from diverse cultural backgrounds

About Our Culture:

We get to create a win-win-win scenario in the marketplace:

  1. We help hospitals achieve improved nurse staffing levels through the placement of caring, international nurses; a win for the patient.
  2. Our clinicians overseas work 24/7 to ensure our patient needs in the U.S. are met through diligent Utilization Management, Health Coaching, HEDIS Gap Closure, Coding, Clinical Documentation Improvement, etc.

We are a nimble team, with virtually no red tape and a keen interest in what is possible.

Our people have the opportunity to take on new challenges in a way that is not available in most other companies. We value career development and achieve this not through emphasizing courses, certifications, and personality tests, but by giving our people an opportunity to lead, manage new projects, and get results.

Check us out on YouTube – we dare you!

We are building an amazing team, and when you join this resourceful, enthusiastic, hard-working group, you will have:

  • A competitive salary
  • Health insurance
  • 401(k)
  • Paid holidays
  • Paid vacation and sick time
  • The opportunity to stretch your wings and build your career in a rewarding, life changing, unforgettable way.

About Shearwater

Because of a shortage of clinicians, it’s difficult to scale healthcare organizations. Shearwater Health provides teams of remote and onsite clinicians that expand the size and impact of clinical teams, so that clients can focus on internal teams practicing at the peak of their license.

From bedside to back-office, there are over 3,000 Shearwater clinicians solving medical and administrative problems every hour of every day all over the world. We couple our clinical expertise with Six Sigma business experts and Robotic Process Automation to improve outcomes and lower costs.

To be successful in our overarching solution to expand the size and impact of U.S. clinical teams both on-site in hospitals and off-shore in the Philippines, we cultivate a dedicated team passionate about finding the right talent and providing that talent with the right tools and training to provide quality work and care.