Gold Coast Health Plan

Program Manager

• Develop and maintain a Quality Coding work-plan and convene committees and workgroups to drive and oversee risk adjustment work
• Implement and oversee quality coding initiatives and projects
• Partner with internal teams and external vendors to monitor program and vendor performance and facilitate improvement activities
• Ensure complete, accurate, timely, and compliant reporting of risk adjustment data in accordance with CMS requirements
• Coordinate, develop, and analyze key indicators, performance data, and reporting tools for risk adjustment operations and quality coding programs
• Define, design, implement, and maintain data files and data extracts for reporting needs
• Maintain knowledge of applicable laws, regulations, and CMS guidance for risk adjustment, Medicare Advantage, and ACA/Exchange requirements
• Deliver provider and staff education to facilitate clinical documentation improvement and improve performance and outcomes
• Review and audit medical record documentation to validate diagnoses and ensure CMS Risk Adjustment compliance
• Support CMS RADV audit readiness, including chart validation, mock audits, record retrieval, documentation reconciliation, and regulatory submissions
• Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider, and vendor performance data
• Partner with Finance to forecast risk adjustments and track coding-quality impact
• Potential travel for auditing purposes
• Perform other duties as assigned

Quality Coding Program Manager

Telesales

• Sell GCHP D-SNP plans over the phone to individuals eligible for the product
• Receive inbound calls from prospects and follow scripts to process applications for enrollment
• Explain Medicare options, plan benefits, and costs to help individuals make informed decisions
• Make outbound calls to follow up and close business in compliance with all regulations
• Successfully complete required product and certification training
• Maintain California Life, Accident and Health Insurance License
• Attend and actively participate in required departmental meetings, training, and coaching sessions

Quality Coding Program Manager

Medicare D-SNP Telesales Agent