Key Responsibilities:
- • Lead and manage a Quality team of 20 to 30 Quality Analysts, ensuring high performance and adherence to organizational standards.
- • Oversee auditors’ daily Productivity and Quality Metrics; track audit timelines and ensure timely delivery of accurate audit results to clients.
- • Conduct team huddles, governance meetings, and ensure effective communication within the team.
- • Perform detailed Error trend analysis; publish recurring error patterns and highlight areas requiring improvement.
- • Conduct and publish Audit the Auditor reports - Validate HCC code assignments based on medical record documentation, ICD‑10‑CM coding guidelines, CMS rules, AHA Coding Clinic updates, and payer-specific requirements. Provide detailed feedback on findings and areas for improvement.
- • Stay current with evolving HCC coding guidelines, CMS regulations, and Medicare Advantage/risk‑adjustment model updates. • Facilitate Quality Calibration sessions with cross‑functional teams to standardize and resolve coding discrepancies.
- • Manage the rebuttal review process - Evaluate coder rebuttals, finalize responses, and ensure accurate alignment with quality standards. • Lead the rebuttals process for external quality audits and reporting.
- • Function as a Subject Matter Expert (SME) for all coding‑related clarifications for Quality Analysts.
- • Act as a communication bridge, ensuring timely and accurate knowledge transfer from client updates to the QA team.
- • Review medical records to identify documentation gaps, inaccuracies, or missing information affecting HCC code assignment.
- • Collaborate with Operations and Training to identify coding trends or recurrent issues affecting quality metrics or reimbursement.
- • Provide constructive feedback, training, and ongoing Education to Quality Analysts on HCC coding guidelines, risk adjustment practices, and documentation standards.
- • Support training initiatives for coding teams on HCC updates, key changes, and corrective measures.
- • Ensure adherence to HIPAA regulations and maintain complete confidentiality of patient information during all audit activities.
Skill Set:
• Minimum 5 years of HCC coding experience (Retrospective / Concurrent / Prospective audits, and HEDIS reviews)
• Minimum 1 Year experience as Team Lead - HCC coding
• Strong knowledge of Human Anatomy, Physiology and Medical Terminology.
• Strong knowledge on Excels, QC Tools like Parato chart.
• Strong Team handling skills
• AAPC or AHIMA certification (e.g., CCS / CRC / CPC) – Mandatory.
Qualifications:
• Bachelor's or Master's in Life Sciences: BAMS, BHMS, BDS, BPT/MPT, B Pharm/M Pharm, B.Sc./M.Sc. (Nursing, Nutrition, Zoology, Biology, Biochemistry, Microbiology, Biotechnology, Genetics, Physician Assistant, etc.)
