PACE Coding Manager - Hybrid

Position Summary:

Responsible for developing, implementing, and maintaining risk adjustment functions and processes for San Diego PACE, leading a team of coding auditors, and facilitating the improvement in overall quality, compliance, completeness, appropriateness, and accuracy of documentation and coding for professional services. 

While reporting to the San Diego PACE Finance Director, will work collaboratively with operations and clinical leadership to improve coding and documentation performance.

Essential Functions of the Job:

• Responsible for developing, implementing, and maintaining risk adjustment functions and processes for San Diego PACE to facilitate improvement in overall quality, completeness, appropriateness, and specificity of documentation.
• Hire, lead, train, and oversee a successful team of coding auditors and manage their performance to create a cohesive and highly effective team.
• Contribute actively to new clinical program development through creation of training tools, resources, procedures, and workflows for providers and San Diego PACE coding auditors.
• Educate, train, onboard, and communicate effectively with the team of providers on accurate, complete, and compliant documentation and coding practices and hold regular and episodic provider training initiatives.
• Assess current compliance activities and evaluate risk factors in coding and documentation practices and implement strategies to mitigate risk by educating providers and coders.
• Responsible for timely review of all billable encounters prior to claims submission for accuracy and completeness and comprehensive concurrent coding reviews and audits of a subset of encounters, with emphasis on documentation quality, accuracy, completeness, compliance, and specificity.
• Establish, implement, and maintain a formalized review process for coding and documentation compliance, including a formal audit process and quality control.
• Communicate with the providers in real time prior to claims submission or redaction through coding queries regarding need for clarification, amendment, or modification of specific patient encounters, following compliant practices to optimize documentation accuracy, specificity, and completeness.
• Work with the provider team and center operations on timely closure of encounters and completion of tasks related to documentation and coding practices.
• Oversee successful and timely bi-annual creation of redaction and submission Risk Adjustment Processing System (RAPS) files to the Center of Medicare and Medicaid Servicer (CMS).
• Contribute to successful transitions of vendors, including Electronic Health Records, to minimize potential burden and vulnerabilities, and improve clarity of expectations pertinent to documentation and coding practices, including development, training, and implementation of new workflows and processes for the impacted teams.
• Meet with external vendors and internal resources and stakeholders monthly to review coding analytics dashboards and reports, gain a deep understanding of current and past performance, identify trends, opportunities, and future strategies, and communicate those with the San Diego PACE leadership team and ensure necessary actions are taken by appropriate teams and individuals to address gaps in performance.
• Stay current with Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM/PCS and CPT coding and serve as a Subject Matter Expert to collaborate and communicate existing and new guidelines with other departments, such as medical practice, operations, and finance.
• Routinely reevaluate existing workflows to identify opportunities for improvements, standardization, or re-education to increase efficiency and accuracy of documentation and coding for all services and providers.
• Serve as a resource to bridge the gaps between the clinical providers and coders and facilitate resolution of documentation and coding issues.
• Provide timely feedback to the coders and auditors and take corrective action to ensure highly effective practices.
• In collaboration with Coders and PACE Finance Director, periodically reviews reimbursement trends by Hierarchical Condition Category (HCC) codes to evaluate opportunities and identify payment issues, making recommendations for changes, as necessary.
• Proficient with ICD-10 and CPT coding as well as E&M and all professional coding guidelines for large multi-specialty provider groups

Additional Duties and Responsibilities:

• Stays current with Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM/PCS and CPT coding. Completes online education courses and attends mandatory coding workshops and/or seminars.
• Provide direction, management, and supervision to ensure efficient operation of assigned departments.
• Coordinate with Other PACE departments to develop standardized processes and gain system-wide efficiencies.
• Function as a cross-functional collaborator, build trust, and communicate effectively with central and site-specific leadership, stakeholders, and providers throughout the organization.
• Performs other related duties as assigned or requested.

Job Requirements

Experience Required:

• 5 years of healthcare experience required; at least 3 years of management experience preferred.
• 3 years of hands-on professional coding experience in large multi-specialty group
• 2+ years of experience as a trainer / educator to physicians and coders

Education Required:

• High School Diploma or GED equivalent

Certifications Required:

• Active and current Certified Procedural Coder (CPC) accreditation by an accredited organization or college, such as the AAPC, that meet the state licensure requirements; Incumbent is required to maintain an “Active” license status as a term of employment.
• CA Driver's license with appropriate insurance coverage

Verbal and Written Skills Required to Perform the Job:

• Excellent verbal and written communication skills
• Comfortable speaking with people at an executive level or physician level
• Ability to communicate effectively both verbally and in writing in English

Technical Knowledge and Skills Required to Perform the Job:

• Experience with EMR system such as Epic preferred but not required.
• Knowledge of Microsoft Office software.
• A thorough understanding of CPT, HCC and ICD-10 coding.
• Math ability to calculate and accurately analyze various accounts.

Equipment Used:

• General office equipment to include PC and Software (Excel, Word, Office), phone, fax, etc.

Working Conditions and Physical Requirements:

• This position is intended to be primarily remote, with a minimum weekly expectation for on-site presence (Provider Education Meetings, etc.)
• General Office Environment; Prolonged periods of sitting, and constant walking and standing.
• May be required to work evenings and/or weekends.
• Some travel required for meetings and trainings.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.