Risk Adjustment Clinical Nurse/Coder (RN/CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA)
About The Position
Then 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). 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.
Requirements
- Associate degree in healthcare administration, nursing, health information management, accounting, finance, or another related field REQUIRED
- Registered Nurse preferred
- One of the following certifications are : 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 medicais records REQUIRED
Nice To Haves
- One-year previous experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital).
- Previous experience with CMS, HHS and/or CDPS+RX Hierarchical Condition Categories (HCC) models.
- Previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.
Responsibilities
- 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
- Reimbursement for certifications and free access to complete CEUs and professional development
- Pet Insurance
- Legal Resources Plan
- Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
