Risk Adjustment Coding Quality Director Guaynabo, PR ABOUT US At Triple S, we are committed to provide meaningful job experiences for Valuable People (Gente Valiosa). We encourage an environment of very high ethical standards, always excelling in service, collaboration among the company, agility to deliver timely, and embracing accountability for results. When you join Triple S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses. Let's build healthier communities together, join now! ABOUT THE ROLE The Risk Adjustment Coding Quality Director is responsible and accountable for the development, implementation, and monitoring of Coding Quality initiatives and training program ensuring accurate and compliant coding practices. The Director will lead efforts to review and validate coding accuracy for right reimbursement with internal staff, PCPs Medical Groups and other resources. In addition, the Director will be responsible for managing the day-to-day operation of RADV audits, regulatory audits, and Risk Adjustment Vendors coding monitoring. Collaboration with multiple departments for operational efficiencies. WHAT YOU'LL DO * Develop strategies to Educate PCPs on HCC and Quality Metrics. Strategies should be focused on accurate coding and right reimbursement related to encounter, chart reviews and other clinical information sources. * Review and report result of medical records reviewed by coding team. Establish corrective action plans, if needed, based on results. * Develop analytics with actuarial teams to identify coding trends and prepare metrics. * Review work plans prepare by Medical Director based on the analysis results * Responsible for educational materials based on identified improvement areas and continuous education on best practices and emerging trends in risk adjustment coding. * Manage and provide direction to designated internal staff. This responsibility includes on-going training, providing direction, and monitoring their productivity and their performance. * Supervise and review work analysis performed by the Medical Director and Risk Adjustment Coders. * Understand vendors operations that are contracted for risk adjustment initiatives to evaluate their performance in accordance with CMS guidelines and educate providers on the use of their tools. * Prepare for and manage external audit processes including RADV. * Work with Risk Adjustment Director to establish and/or modify risk score initiatives based on analysis performed. * Develop and implement coding quality assurance protocols. WHAT YOU'LL BRING Master's degree in business, or Healthcare Administration, or related field with at least 7 years in Health segments, preferably in the insurance and health industry. Bachelor's degree in business, or Healthcare Administration, or related field with at least 10 years in Health segments, preferably in the insurance and health industry At least 7 years of supervisory experience. CLOSING DATE: 8/25/2024 It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, gender, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company. Equality Employment Opportunity/Affirmative Action for Minorities/Females/People with Disabilities/Veterans". Employer with E-Verify to verify the eligibility of employment of all the new employees. We encourage Females, Veterans and Disabled to Apply