Manages and influences the complex Medicare Recovery process, related projects or programs with Regional and National resources. Manages, coordinates and evaluates the activities of personnel engaged in Medicare Risk Adjustment audits and related projects. Responsible for coordinating efforts with National and Regional CPMG, Revenue Cycle, Coding, and Medicare Finance leaders, with the goal of ensuring accurate and timely submissions to CMS. Maintains and optimizes the encounter data flow from end to end. Responsible for the continuous coordination and monitoring between multiple disciplines including: Coding, IT, Medicare Finance, PBS, CPMG and Operations. Provides recommendations and remediation of deficiencies. Responsible for the related changes in policies, training and configuration. Accountable for creating a culture of compliance, ethics and integrity. Maintains knowledge of and assures departmental compliance with Kaiser Permanentes Principles of Responsibility and policies and procedures, and applicable regulatory requirements and accreditation standards. Responds appropriately to observed fraud or abuse.

• Ensures maximum Center for Medicare and Medicaid Services (a.k.a. CMS) compliance and reimbursement by coordinating multi-disciplinary departmental roles in the CMS data flow.
• Responsible for representing Colorado Medicare SOX Mega and for the identification and remediation of SOX related issues.
• Responsible for optimization of the alerts and reminders process.
• Responsible for the optimization of the un-refreshed diagnosis process.
• Manage the annual initiatives to capture un-refreshed diagnosis and data flow.
• Participates in National and CMS driven Medicare Risk Adjustment audits and related projects (i.e., Benchmark, Probe audits).
• Develops and coordinates, in conjunction with the Coding Department, CMS education for all clinical staff.
• Responsible for monitoring yearly CMS changes related to ICD-9 codes.
• Develops and maintains a compliant process to add and redact diagnoses captured from internal audits.
• Investigates system configuration changes that will augment compliance and reimbursement.
• Responsible for Part D RxHCC.
• Supervises direct reports; including interviewing, selecting, training, motivating, evaluating, counseling, disciplining and terminating in compliance with EEO/AA goals and personnel policies of the organization.
• Maintains current information and knowledge of all applicable Kaiser policies, local, state and federal laws and regulations, and accreditation standards. Ensures that the training activities incorporate all applicable KP policies, local, state and federal laws and regulations, and accreditation standards.