Risk Adjustment - Risk Adjustment Coding Analyst 135-2014

CommunityCare•Tulsa, OK

About The Position

This role will report directly to the Supervisor of Clinical and Risk Coding and is responsible for clinical and risk adjustment audits for both Medicare Advantage and ACA Programs. Ensuring accurate and appropriate documentation. Audits include Vendors, provider groups, and individual providers. Will also provide medical coding support and HEDIS assistance to the Reporting department. This role will support all seasonal and ad-hoc project assignments for both clinical and risk adjustment.

Requirements

Extensive knowledge of ICD, HCPCS, and CPT codes.
Health plan/medical practice experience
Able to work independently and meet stringent deadlines.
Strong attention to detail.
Possess strong oral and written communication skills
Successful completion of Health Care Sanctions background check.
Proficient in Microsoft Office applications.
Coding certification nationally recognized by the AAPC or AHIMA is required.
Minimum of two years of coding experience utilizing ICD-CM coding required.
Experience or familiarity with state and federal regulations governing healthcare.

Nice To Haves

Knowledge of risk adjustment payment models and risk adjustment coding preferred
Familiarity with State and federal regulations governing healthcare preferred
Medicare Advantage and ACA knowledge preferred
Two years’ experience with claims processing systems, coding programs, and electronic medical records preferred.
Previous HMO or health insurance experience preferred.

Responsibilities

Ensure ICD codes submitted to CMS for the Risk Adjustment Payment System are accurate, appropriate, and supported by written clinical documentation in accordance with all federal and state regulations.
Adhere to all official coding rules and CMS guidelines for risk adjustment programs. Ensure accuracy, completeness, specificity, and appropriateness of diagnosis information.
Surveillance of CPT, CMS, and other regulations and their impact related to coding and other business functions.
Risk Adjustment Validation Audits (RADV), conduct chart review of inpatient and outpatient medical records for Hierarchal Condition Category (HCC) coding.
Review results of risk adjustment audits to identify coding patterns and provide the information back to the supervisor.
Provide accurate data results/reports of provider claims and clinical notes audited.
Recommend general and specific education topics based on CMS/HHS guidelines to the supervisor in written form (e.g., email, word, etc.)
Meet with the supervisor to discuss potential education with the provider groups and other stakeholders to provide coding education and support.
Assist with the annual HEDIS medical record review process.
Receives assignment to evaluate Medicare Wellness Visit documentation for accuracy and completeness in addressing gaps in care and expiring HCCs. Present findings to the supervisor on a regularly scheduled basis.
Perform evaluation /prioritize results of new Medicare Advantage and Marketplace member self-reported health risk assessments for risk adjustment conditions that should be addressed. Create analyses, summary reporting, and coordinate with providers
Provide support to health data analysts on medical coding questions and follow up with the supervisor on any issues that need to be resolved.
Support medical record requests and retrieval projects.
Perform other job-related duties as assigned.