Medicare Risk Adjustment Coding Specialist- Remote

TruHealth•Franklin, TN

17h•Remote

About The Position

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Requirements

Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment to include the review of regulatory announcements via educational sessions provided by regulatory entities and educational opportunities within the industry.
Follow all appropriate Federal and state regulatory requirements and guidelines, as well as company policies and procedures.
Maintain established levels of production and quality standards.
Knowledgeable of CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations.
Knowledgeable of coding/auditing claims for Medicare and Medicaid plans.
Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing.
Strong interpersonal skills.
Excellent written and verbal communication skills.
Strong organizational skills; ability to time manage effectively.
Maintain confidentiality.
Strong analytical and critical thinking skills required.
Ability to work remotely without direct supervision.
Successful completion of required training.
Handle multiple priorities effectively.
High school or equivalent degree.
2 years’ experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system.
2 years’ experience in managed healthcare environment related to claims and/or coding audits.
2 years’ experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others.
2 years’ experience with CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations.
2 years’ experience coding/auditing claims for Medicare and Medicaid plans.
Significant HCC experience (including knowledge of HCC mapping and hierarchy).
Coding certification required (CPC or CRC).

Responsibilities

Conducting coding audits prior to payment release.
Performing post-payment coding reviews with overpayments.
Sending coding education correspondence to applicable providers.
Reviewing medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes based on services rendered.
Assisting with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement.
Interpreting medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured.
Developing tools and metrics to improve accuracy and completeness of coding and documentation.
Providing a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards.
Escalating appropriate coding audit issues to management as required.
Participating in and supporting ad-hoc coding audits as needed.
Supporting ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit.
Working assigned coding projects to completion.
Other duties as assigned.