Risk Adjustment Coding Coordinator I/II at Excellus Health Plan Inc. in Rochester, New York

Job Description:

Job Description:

Summary:

Under the direction of the Team Leader, Risk Adjustment Program Operations, the Risk Adjustment Coding Coordinator is responsible for various aspects of decision-making and implementation of medical coding reviews and coding policies to ensure accurate revenue to the Health Plan across all geographic regions. This position is responsible for risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

• Prospective medical record review of health plan providers


• Retrospective medical record review of health plan providers


• Risk Adjustment Data Validation (RADV) Audits

Essential Primary Responsibilities/Accountabilities:

All Levels:

Level I:

• Serves as a coordinator and key business resource for the Risk Adjustment Coding Coordination Team.


• Serves as a subject matter expert for ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial Hierarchical Condition Category (HCC) coding, and Medicaid Clinical Risk Groups (CRGs).


• Reviews medical records to determine if specific disease conditions were correctly reimbursed and documented. Reports findings of the data validation review. Prepares and submits adjustments to the appropriate processing / adjustment area (Risk Adjustment, Actuarial Services).


• Performs vendor Quality Assurance (QA) and internal Revenue Generating (RG) coding projects, including over read assignments. May support vendor discussions and feedback related to quality audit findings. Presents results and learning opportunities to the team.


• May participate with department members and other operating teams in developing, implementing, evaluating and updating desktop processes, policies and procedures and business rule tools governing the response to Risk Adjustment Data Validation (RADV) Audits, prospective medical record coding, and retrospective medical record coding.


• Works with vendors, providers and hospital Medical Records Departments and Business Office staff to coordinate medical record access and reviews in a timely fashion.


• Develops and submits monthly medical coding articles to the Health Plan Connection Newsletter and to the Univera Healthcare Examiner newsletter.


• Meets or exceeds productivity targets as established by management. Regularly meets due dates as assigned.


• Ensures project activities are in compliance with applicable coding guidelines, NYS law, and federal regulations.


• Provides peer to peer guidance through informal discussion and over read assignments. Supports coder training and orientation as requested by the Risk Adjustment Program Operations Training Manager and Team Leader Risk Adjustment Program Operations.


• Maintains accuracy in all coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences as required by AHIMA and / or AAPC to maintain professional certification. Presents information from professional activities to management and staff as applicable.


• Keeps management apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.


• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.


• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.


• Regular and reliable attendance is expected and required.


• Performs other functions as assigned by management.

Level II (in addition to Level I essential responsibilities/accountabilities):

• Serves as a liaison between the Plan and designated representatives of the provider office and/or hospitals and vendor(s) in aspects of prospective and/or retrospective coding and quality assurance validation reviews for members. This can include but is not limited to requesting and retrieving medical records from providers to the plan for review, data element verification, ICD-9-CM / ICD-10-CM coding validation, monitoring plan specifications, Hierarchical Condition Category (HCC) assignment accuracy and Risk Adjustment Validation Audits (RADV).


• Acts as a preceptor to new employees during the orientation process. Functions as a resource to existing staff for projects and daily work. Facilitates ongoing training for optimal staff functioning.


• Researches "best practices" in risk adjustment coding and reviews the professional literature for coding updates, maintaining currency in coding. Evaluates, researches, and recommends enhancements to the risk adjustment program and internal coding guidelines.


• Proposes and develops new desk level procedures (DLP's) and policies and procedures (P&P's) as needed to support new and existing department initiatives, audits, and projects. Reviews and updates existing DLP's, workflows, and P&P's to ensure accuracy. Establishes and maintains a repository for storing department documentation which may include corporate share drives, wiki, company intranet, and/or corporate website. Collaborates with other operating teams as needed in order to support these activities.


• Will occasionally lead workgroups and manage project deliverables for department projects, policy and procedure reviews, revenue generating initiatives, audits, and provider newsletter articles / communications.


• Provides written or oral recommendations to management related to process improvements, root-cause analysis, and/or barrier resolution applicable to Risk Adjustment initiatives.


• Analyzes and researches provider diagnostic coding issues and patterns through medical record review. Identifies and offers education in relation to provider coding errors and documentation standards as requested by management and in conjunction with the Provider Outreach Coordinator.


• May be assigned additional over read projects/higher work volume than Risk Adjustment Coding Coordinator I.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels:

• High school Diploma required with Current Coding Certification (CPC, CPC-H, CPC-I, CCS) through AHIMA or AAPC. A minimum of one (1) year coding experience or directly related medical experience is required. In lieu of required certification and coding experience, a CPC-A or CCA certification is required.


• Knowledge of medical terminology and disease processes


• Knowledge of medical coding methodologies, conventions and guidelines (e.g. ICD-9-CM, ICD-10, CPT, HCPC)


• Familiarity and understanding of CMS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements, preferred.


• Strong proficiency with Microsoft Office applications (Word, Excel, Access, and PowerPoint)


• Strong written and verbal communication skills; strong analytical, organization and time management skills required.


• Prolonged sitting and standing.


• Able to work independently and within time constraints.


• Recognizes and properly handles confidential health information.


• Able to efficiently prioritize multiple high-priority tasks.


• Previous auditing experience desirable.

Level II (in addition to Level I minimum qualifications):

• A minimum of two (2) years coding experience or directly related medical experience, one (1) of which includes Hierarchical Condition Category (HCC) coding.


• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.


• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems. This includes a comprehensive understanding of ICD-9, ICD-10, and other types of coding submitted to the Health Plan by contracted facilities, and providers.


• Advanced technical skills for use of MS Office (Excel, Word, Access, and PowerPoint).


• Demonstrated ability to utilize a variety of electronic medical records systems.


• Ability to manage significant work load, and to work efficiently under pressure meeting established deadlines with minimal supervision. Strong time management skills. Must possess high degree of accuracy, efficiency and dependability.


• Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization both verbally and written.


• Demonstrated organizational and problem-solving ability.


• Strong analytical and mathematical skills.


• Demonstrated experience in project completion, educational program development and/or group presentation.


• Knowledge of healthcare industry.

Physical Requirements:

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Level I: Grade 205: Minimum $56,347 - Maximum $81,702

Level II: Grade 206: Minimum $56,534 - Maximum $93,267

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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