Risk Adjustment Clinical Nurse/Coder (RN/CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA)
About The Position
AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Risk Adjustment Nurse/Coder. This role performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS). The position involves prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. It also includes reviewing provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC). The role supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities. It also conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight. Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding. Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns. Serves as subject matter expert on risk adjustment diagnosis coding guidelines. Coordinates risk adjustment gap elimination with clinical and quality gap elimination. Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.
Requirements
- Associate degree in healthcare administration, nursing, health information management, accounting, finance, or another related field REQUIRED
- One of the following certifications are REQUIRED: Register Nurse (preferred), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
- Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment.
- 2 years of medical coding experience. In lieu of associate's degree, 4 years of medical coding experience REQUIRED
- Must have thorough knowledge and understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics.
- One-year previous experience with paper and/or electronic medical records REQUIRED.
Nice To Haves
- Register Nurse (preferred)
- One-year previous experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital).
- Prefer previous experience with CMS, HHS and/or CDPS+RX Hierarchical Condition Categories (HCC) models.
- Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.
Responsibilities
- Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS).
- Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits.
- Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC).
- Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities.
- Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight.
- Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding.
- Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns.
- Serves as subject matter expert on risk adjustment diagnosis coding guidelines.
- Coordinates risk adjustment gap elimination with clinical and quality gap elimination.
- Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.
Benefits
- Medical, Dental, Vision plans
- Adoption, Fertility and Surrogacy Reimbursement up to $10,000
- Paid Time Off and Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term, Short-Term Disability, and Critical Illness plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
- Student Debt Pay Down – $10,000
- Pet Insurance
- Legal Resources Plan
- Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
