CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA)

Sentara Hospitals•Miami, FL

9d•Hybrid

About The Position

AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Risk Adjustment Nurse/Coder (RN/CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA in Doral, FL! This is a full-time permanent position (40 hours) with standard working hours from 8 am to 4:30 pm EST, Monday to Friday. This is a hybrid position, requiring 2 days onsite in AvMed Doral Office, 3470 NW 82nd Ave Suite 1100, Doral, FL 33122, and 3 days remote. The Risk Adjustment Clinical Coder/Nurse 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). They perform prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. The role involves 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). This position 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 includes conducting annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight. The role performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding and makes the final decision on vendor-to-vendor diagnosis coding rebuttal concerns. The individual serves as a subject matter expert on risk adjustment diagnosis coding guidelines and coordinates risk adjustment gap elimination with clinical and quality gap elimination. They maintain a reasonable fluency in the 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

Prefer one-year 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
Annual discretionary bonus if established system and employee eligibility criteria is met.