This key role will provide coding support in the evaluation, and performance that support the mandated CMS RADV audits as required for both ACA and MA segments, targeted risk mitigation audits and federal mandated audits. This position will require the candidate possess analytical and strategic thinking skills typically attained from experience with interpreting CMS and HHS regulations and participation in the audit process.
Performs medical record reviews to ensure documentation supports submitted CMS and HHS Hierarchical Condition Categories (HCC) conditions for Commercial and Medicare Risk Adjustment Payment system.
Ensure diagnosis codes are supported by the documentation and ensure adherence with ICD-10CM, AHA Guidelines for Coding and Reporting.
Maintains up-to-date coding knowledge by reviewing materials disseminated and/or recommended by clients and managers.
Participates in coding department meetings and educational events.
Contributes to the quality improvement activities of the department and the organization including participating in internal department and client audits.
Communicates audit findings effectively and professionally by preparing summary reports
Reports trends and opportunities to improve coding and clinical documentation opportunities.
Makes corrections (additions and deletions) as needed to ensure accurate submission of HCC codes to CMS
Possess and maintain a comprehensive understanding and knowledge of company business, products, programs, organizational structure, and basic research principles/methodologies.
and assists management in implementing programs that provide solutions.
Assists leadership by investigating, reviewing, and recommending innovative solutions which identify problems/root cause of issues.
Assists with and documents feedback between corporate business areas and participates in group or committee discussions.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
High School diploma or GED equivalent required. Bachelor's degree in a related field preferred. Certificate/License (CPC, CPC-H, CRC, CCS-P, CCS) required. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required.
Minimum of five (5) years HCC specific coding experience required. Experience and understanding of CMS HCC Risk Adjustment coding and data validation requirements. 3 years RADV audit experience in health plan operations.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Extensive knowledge of RADV audits and Risk Adjustment.
Strong analytical, planning, problem solving, verbal, and written skills to communicate complex ideas.
Ability to develop project management, meeting process, and presentation skills.
Strong ability to work independently and direct the efforts of others.
Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc.).
Ability to work independently, within a team environment, and communicate effectively with employees and clients at all levels.
Work is performed in an office setting with no unusual hazards.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.