Job Description

Job Summary:
The Quality Clinical Management Senior Manager is a key operational and strategic role responsible for executing a comprehensive Risk Adjustment coding data quality program focused on improving the accuracy and completeness of data submitted to CMS in support of HHS’ Risk Adjustment and other IFP programs. The Senior Manager oversees a multi-functional team which sets IFP Risk Adjustment policy & processes, executes provider auditing & reporting to support education, and reviews, analyzes, and reports on data to meet business goals and objectives.

Core Responsibilities:
Leads multiple cross-functional and vendor-solution focused teams engaged in risk adjustment operations, including diagnostic code abstraction, quality and compliance auditing, provider documentation audits, and other data analysis of clinical, billing, and coding data, as required, in the compliant execution of HHS’ Risk Adjustment program.

Oversees development and execution of workflows and processes related to risk adjustment data accuracy and execution of HHS RADV Audits.

Evaluates and communicates staffing requirements & recommendations to ensure sufficient ratios to effect high-quality, compliant, and thorough execution and meet business objectives and organizational goals.

Manages existing Risk Adjustment Operations vendor relationships supporting RADV and Risk Adjustment program activities.

Develops Risk Adjustment data accuracy auditing and controls, including concurrent and retrospective targeted audits, ongoing risk analytics, and identification of systematic interventions to improve data accuracy.

Partners with colleagues to develop and manage internal tools & technology focused on operational effectiveness and accuracy of diagnostic coding quality.

Serves as program subject matter expert for facilitation of education of internal and external stakeholders. Develops and deliver provider education programs on risk adjustment coding requirements to providers, and vendors, to ensure that there is a comprehensive understanding of requirements for clinical documentation to support Risk Adjustment and RADV initiatives.

Develops performance targets for both internal and external constituents.

Integral contributor to Supplier Statement of Work generation, in conjunction with Cigna Global Procurement, serving as subject matter expert, ensuring performance targets are set and appropriate to program.

Manages the development and implementation of coding education curriculum for internal coders, vendor coding teams, and provider partners, as appropriate, to improve understanding of, and execution of, coding guidelines.

Works with other leaders across the segment to implement provider incentive programs that drive chart retrieval, provider accuracy and completeness in coding. Partner to find innovative ways to close quality and clinical gaps through technology or other methods.

Uses analytics to define Risk Adjustment Coding Quality focus, identifying areas to increase quality and maximize opportunities.

Works collaboratively with the Risk Adjustment Data & Analytics team to drive improvements in existing processes and find new opportunities for identification of risk score opportunities, analysis and tracking of performance.

Maintains up-to-date knowledge on CMS’ legislation and regulations regarding Risk Adjustment & RADV. Assesses the operational and strategic impacts to coding quality of any changes in the programs and serves as an advocate for new changes.

Works with Compliance and Legal teams to ensure Risk Adjustment and RADV coding efforts are in compliance with all rules and regulations, including but not limited to Coding Guidelines, CMS Protocols, and Federal Regulations. Sponsors and leads internal Coding Oversight Committee to facilitate communication of standards and practices across all partners.

Prepares and presents status updates to Senior Leaders, as requested.

Minimum Qualifications

A Bachelor’s Degree and 8 - 10 years’ experience in healthcare, or equivalent combination of relevant education and work experience
RN, NP, or related current clinical license preferred
Payer or provider operations and relations or other related experience helpful
Position requires at least three years of experience with HHS’ ACA Risk Adjustment and RADV
Certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) in one of the following certifications:
Certified Professional Coder (CPC)
Certified Coding Specialist for Providers (CCS-P)
Certified Coding Specialist for Hospitals (CCS-H)
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Risk Adjustment Coder (CRC) certification

Proficiency with ICD-10-CM coding and guidelines; Multiple certifications a plus
Familiarity with CMS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation
HCC coding experience required
Computer competency with Excel, MS Word, Adobe Acrobat
Risk adjustment knowledge and expertise across Medicare, Medicaid, and Commercial exchange preferred
Demonstrated success in improving Risk Adjustment measures, managing multiple vendor relationships and leading cross-functional teams
Ability to prioritize tasks with competing deadlines. Capacity to Multi-task in a highly detail-oriented and dynamic environment
Solid analytical and logical skills paired with strong attention to detail
Experience with driving provider coding quality and value based reimbursement arrangements preferred
Demonstrated change agent skills within a matrix environment
Ability to deal with ambiguity and to turn plans into actions
Candidate must possess great oral and written communication skills

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 111,800 - 186,400 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

About Cigna Healthcare
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

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