Risk Adjustment Coding Specialist

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Conducts coding reviews independently on all provider documentation to assign the correct ICD-10 codes and ensure all documentation is accurate, precise, and adherent to CMS guidelines pertinent to Risk Adjustment Hierarchical Condition Category (HCC) methodology once a project is assigned. Outreaches supervisor for non-routine issues and new situations.
• Completes monthly internal data validation of sampled Risk Adjustment diagnoses submitted by external stakeholders.
• Responsible for ensuring completion of medical record reviews based on monthly target set forth by department.
• Keeps current on new coding and billing guidelines and federal and state initiatives regarding claims and educates other departments on new/changes to regulations.
• Regulatory Oversight and Quality Assurance and performs medical record compliance audits using the most up-to-date CMS guidelines, output generated is submitted to CMS to accurately capture member's acuity resulting in a compliance and financial impact to the organization, maintains high level of quality and production standards required by leadership to ensure continued medical coding accuracy. This requires advanced knowledge, certifications, and experience related to coding/auditing of ICD 10 Diagnoses based on HCC category.
• Provides audit trail for all identified HCCs in a Medical Record Review through use of audit tool.
• Identifies all unsupported diagnoses/HCCs for all Risk Adjustment Data Validation (RADV) related projects and appropriately notifies management of deficiencies to report to Encounter submissions team.
• *Maintains high level of quality and production standards required by leadership to ensure continued medical coding accuracy.
• Provider Engagement, Audit, Training and Support and supports supervisor in preparing internal presentations, knowledge libraries, coding guidelines, and summary reports of coding review for department infrastructure, maintains professional communication with provider engagement team by assisting with analysis, trending, and presentation of audit/review findings, outcomes, and issues
• Engages with medical practitioners to provide feedback and educational resources on best practices for medical coding and keeps current on new coding and billing guidelines, federal and state initiatives regarding claims and educates other departments in new/changes to regulations.
• Reports incidental findings, patterns, and trends from audits/coding projects to supervisor thus assisting supervisor in analyzing audit results, tracking and trending. Responsible for supporting supervisor/manager for testing of Coding/Audit tool to ensure appropriate functioning, identifying trends, making recommendations for process improvement for ensuring compliance.
• Enterprise Wide Risk Adjustment Collaboration Activities and Initiatives and support Manager in driving enterprise-wide risk adjustment initiatives. Collaborates internally with Special Investigations and Compliance supporting medical record review and claims analysis for determination of provider engagement in fraud, waste and abuse. Provides guidance to claims team, SIU, and other teams related to ICD 10 Diagnoses codes, CPT and HCPCS codes related to Risk Adjustment in addition to identifying updates for all measures and contract billing codes, as necessary.

Licenses and Certifications:

• Active Certified Coder Certification through AHIMA or AAPC preferred
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or (CRC) Certified Risk Adjustment Coder in ICD-10-CM coding preferred

Education:

• Bachelor's Degree or equivalent work experience required

Work Experience:

• Minimum three years of payor work experience with medical records, including ICD-10-CM or current coding system and medical record systems required
• Working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits required
• Additional years of experience/specialized certification/training may be considered in lieu of educational requirements required
• Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures required
• Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required
• Strong planning, organizational, interpersonal, verbal and written communication skills required
• Must be PC literate and possess a strong understanding of Microsoft applications required
• Ability to handle multiple priorities and meet deadlines required
• Knowledge of HIPAA, understanding a commitment to Privacy, Security and Confidentiality of all medical chart documentation required
• Ability to work both in a fast-paced environment and/or be independently self-driven to complete day to day tasks required
• Ability to switch gears and independently collaborate with other departments for all ad lib projects as necessary required