Risk Adjustment Coding & Documentation Specialist

Sentara Health

7d

About The Position

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 required in healthcare administration, nursing, health information management, accounting, finance, or other related field with 2 years of medical coding experience.
• In lieu of Associates 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.
• One of the following certifications are required: 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.

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 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees