Manager, HIMS Coding & Revenue Operations

Description:
This position is accountable for the management and maintenance of the Regional Strategic Operational Coding Management and Validatio/Auditing Program for operationally compliant coding, documentation and revenue cycle in all applicable health care settings. The strategic partners/groups include TSPMG practitioners, Compliance, Claims Operations, Revenue Cycle, affiliated network providers and facilities. The Regional Strategic Operational Coding and Validation/Auditing Program will provide for holistic Regional Coding, Documentation and Revenue Cycle Plan which will include development of relevant audit tools, determination of statistically meaningful audit samples for each of the target audiences, conduct of audits, analysis, reporting and communication of audit results and verification that any required corrective action plans-including relevant training programs-are developed, implemented, completed and evaluated to assure any deficiencies noted are corrected. This position will be accountable for the completion of independent audit results to determine accuracy of medical coding, completeness of documentation of practitioners and/or clinical staff and appropriateness of reimbursement or payments within each of the targeted groups. This position is responsible for the management of various types of work queues with valued services in the millions. Work queue types include charge router, charge review, denials, and custom, etc. This role will insure operational coding, documentation and revenue cycle practices across the region are carried out in a consistent and compliant manner as directed by policies and procedures guaranteeing the delivery of superior health related services to our members and providers. Creates and updates policies and procedures, monitors quality control/quality assurance of documentation /coding, performs analysis and oversees operational coding activities that support the region for both Health Plan. Partners with Strategic Leaders in Provider Contracting, Claims Operations, Medicare Operations, Medicare Finance, Compliance, Revenue Cycle and Medicare Contract Compliance regarding the regions coding, documentation, and reimbursement submissions. Keeps abreast of all state and federal regulations and industry related standards; and maintains documentation of policy & procedure compliance of all pertinent regulations, including but not limited to the Office of the Inspector General (OIG) work plan. Insures all activities are compliant and meet Sarbanes-Oxley (SOX) requirements, this includes monitoring, reporting, and adjustments to workflows as appropriate. Supports the Regional Process for response to National Compliance, Ethics and Integrity Office (NCO) and other external audits as needed. Prepares the records for submission. Provides an pre-analysis and outcome expectation to regional leadership.

• Develop, implement, oversee and evaluate the annual Regional Strategic Coding/ Auditing Program for compliance, coding documentation and revenue cycle including development/revision of applicable audit tools to include accuracy of all ICD-9-CM, CPT-4 and HCPCS Level II code assignments, assessment of adequacy of professional documentation to support the codes chosen and developing and implementing audit tools to measure the end to end revenue cycle process within the Region. Facilitate and manage the conduct of audits, ensure the accuracy of findings and prepared audit reports and recommendations and oversee the development, implementation, completion and evaluation of effectiveness of corrective action plans for all noted deficiencies. Communicate reports to the Regional HIMS, TSPMG, and Compliance Directors, applicable managers, the Physician Program Director Coding and Documentation and others as appropriate/requested.


• Insure the development and presentation of training and education programs for affiliated providers and their coding/billing staff on existing and future coding, reimbursement, and risk-adjusted severity of illness systems.


• Provide operational oversight and management of HIMS Coding and designated administrative staff.


• Interviews, hires, trains, disciplines, evaluate, counsels and terminate in conformance with EEO/AA goals, personnel policies, and organizational objectives.


• Assure development, implementation, completion and evaluation of effectiveness of corrective action plans for all noted deficiencies.


• Oversee the identification of trends, patterns, system issues that may contribute to coding, documentation and revenue cycle deficiencies as identified by HIMS Coding Analysts. Make recommendations to Regional Coding and Documentation Oversight Committee and relevant managers for actions that may alleviate deficiencies for the target group (e.g. training, oversight, and monitoring, process flows).


• Verify that all audits are based on the most current regulatory and reimbursement requirements at both the state and federal level.


• Ensure that audit records and tools are maintained for a minimum of 10 years to include audit plan for a given year, audit tools, reports (including recommendations) of all audits conducted, and copies of completed corrective action plans.


• Maintain close working relationship with Local and National Compliance Program to assure integration of audit planning, communication of all results, and ongoing development of tools applicable to all Regions.


• Manage participation with National Compliance program to assure maximum utilization of coding resources in conduct of probe audits and other audits for contracted providers and contracted facilities.


• Partners effectively with strategic regional leadership such as Provider Contracting, Claims Operations, Medicare Operations, Medicare Finance, Compliance, Revenue Cycle, Benefits Administration and Medicare Contract Compliance to enhance financial products, services, interrelationships among systems and processes across functional areas. Leads redesign processes to improve efficiency, and ensure optimal results. Drives change management to insure effective use of health information data through analyses of reports, quality, utilization, research, billing and other vital functions. Manages and resolves human resource, employee and department safety and risk management issues.


• Collaborates with clinical and non-clinical groups within the program to develop, implement and communicate specific coding, documentation and revenue cycle guidelines to fulfill internal quality data needs. Interprets national, state and KP-specific coding, billing and documentation guidelines for KPs leadership, attorneys, physicians, coders, compliance and billers to ensure consistent and accurate implementation and compliance with external regulations.


• Facilitate active and relevant participation by HIMS Coding staff on applicable Regional and National Coding Compliance Committees.


• In partnership with Compliance leadership and TSPMG Professional Staff Development leadership, provide content for training programs.


• Assess the effectiveness and ease of use of all audit tools and revise as necessary.


• Consistently supports HIMS Coding and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.


• May perform other duties as assigned.


• In addition to defined technical requirements, you will be accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Promise, and specific departmental/organizational initiatives. You also will be accountable to consistently demonstrate the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.