Director of Burden of Illness (BOI)

Fort Myers, FL

Millennium Physician Group

The Director of BOI is responsible for overseeing, coordinating, or perform data reviews and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine annual risk adjustment program strategies to achieve optimal performance. S/he should foster and maintain vendor and carrier relationship to help drive optimum program success and meet contractual obligations. Identify areas of opportunity via reporting and workflow improvement throughout the organization. Collaborate between all areas of the organization to ensure success of our value-based coding initiatives such as provider engagement, education, prevalence rates, coding opportunities, documentation compliance and medical margin. The Director is tasked with improving the Risk Adjustment department through innovative technologies, leading, and growing the team and exploring future programs to enhance our position in Value Based Programs.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Ensure compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment.
• Develop, Train and lead staff to review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify whether:
  • The diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.
  • The diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted timeframe.
  • Any diagnosis code identified as being unsubstantiated by the record must be submitted to the carrier within timely guidelines to ensure on supported codes remain on record with those carriers.
  • Review for clinical indicators and query providers to capture the severity of illness of the patient.
• Measure Providers' performance on important aspects of care and service through data reviews and data-driven analysis
• Communicates and coordinates reviews with RA Provider Educator and Support Services for use in provider training sessions.
• Facilitates and coordinates reporting to leadership within the organization as requested
• Manages the BOI Team in a positive manner with emphasis on providing excellent service to all patients, providers, internal and external customers.
• Communicates to supervisor and IT Department regarding defects identified in the reporting systems or data base, suggests performance improvement opportunities and tracks through completion to insure revenue capture.
• Confirm code capture and proper RAF calculations by carriers.
• Provides reporting for revalidation of codes, accept, and reject rates, code trends for areas of opportunity. Reporting by carriers, provider, POD, etc.
• Assist with identifying and developing technology to enhance risk adjustment operations and accuracy
• Health plan ASM/EDS data submission or reconciliation
• Provides clear, concise and professional communication to varying audiences depending on the project and its goals.
• Demonstrates excellent time management, attends and contributes to required meetings which may include travel as well as hours outside of standard business hours and/or above 40 hours per week.
• Demonstrates the ability to train new leaders or provide ongoing education and training to existing staff/leaders along with regularly performing quality reviews and including feedback on opportunities for improvement to the Risk Coding team.

Supervisory Responsibilities

Directly supervises assigned employees in the Risk department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Adaptability - Maintaining effectiveness in varying environments and with different tasks, responsibilities, and people.

Analysis/Problem Assessment - Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.

Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.

Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.

Compliance - Employee has satisfactory completed employers required compliance training.

Employee is able to demonstrate an understanding of employers Code of Conduct.

Dependability - Meets commitments, deliverables, deadlines, work independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, and meets attendance/punctuality requirements.

Follow-up - Establishing procedures to monitor the results of delegations, assignments, or projects; taking into consideration the skills, knowledge, and experience of the assigned individual and characteristics of the assignment or project.

Initiative - Making active attempts to influence events to achieve goals; self-starting rather than accepting passively; taking action to achieve goals beyond what is required; being proactive. Practices self-development.

Integrity - Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities.

Judgement/ Problem Solving - Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others.

Patient Service Orientation - Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence.

Practical Learning - Assimilating and applying, in a timely manner, new job-related information that may vary in complexity.

Quality Orientation/ Attention to detail - Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.

Results Driven& Execution - Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative. Team work/ Collaboration - Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions.

Technological /Professional knowledge - Having achieved a satisfactory level of technical and professional skills/knowledge in job-related areas; keeping abreast of current developments and trends in area of expertise.

Work Standards - Setting high goals or standards of performance for self, direct reports, others, and the organization; being dissatisfied with average performance; self-imposing standards of excellence rather than having standards imposed by others.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Enrolled/or completed in Bachelor's degree from four-year college or university; And one to two years related experience and/or training; or equivalent combination of education and experience. Position requires flexibility in work hours, multi-tasking, and excellent computer skills. CRC and /or CPC preferred.

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Mathematical Skills

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have proficient knowledge of Microsoft Excel Spreadsheet software; Microsoft Word Processing software, Outlook and ADP Payroll systems. Knowledge of Computers, Fax, Portals, Uploading, Downloading, Athena or other Electronic Medical Record System.

Certificates, Licenses, Registrations

N/A

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate depending on business activity of the office.