Risk Adjustment Coding Specialist-Excellus-Remote

Trinity Health

20h•Remote

About The Position

The Risk Adjustment Coding Specialist works in a team environment and is responsible for reviewing clinical documentation and coding using HCC (Hierarchical Condition Category) and M.E.A.T (Monitored, Evaluated/Assessed, Addressed, Treated) standards while adhering to coding guidelines established by the Centers for Medicare and Medicaid Services (CMS). This role involves reviewing and assigning accurate ICD-10-CM codes for diagnoses, utilizing billing system work queues and natural language processing (NLP) tools to address HCC codes for Risk Adjustment before claim submission. The specialist will demonstrate a solid understanding of ICD-10-CM coding, medical terminology, HCC, and M.E.A.T standards, as well as coding guidelines, payer regulations, compliance, reimbursement, and the impact of coding on risk adjustment payment models. They will also identify coding discrepancies and communicate deficiencies to providers in collaboration with the risk adjustment auditor. The position requires adherence to St. Joseph’s Health’s confidentiality requirements regarding patient information and participation in continuing education to maintain certifications.

Requirements

Certified Risk Adjustment Coder (CRC) required or Certified Professional Coder (CPC) and CRC to be obtained within 12 months of hire
Excellent verbal and written communication skills.
Customer service-oriented attitude/behavior.
Detail oriented with the ability to multi-task and complete tasks in a timely manner.
Ability to work well as a team member.
Intermediate computer skills: typing, 10-key, Word, Excel, Outlook and Teams.
High School Diploma or GED
Must be able to set and organize own work priorities and adapt to them as they change frequently.
Must be able to work concurrently on a variety of tasks/projects in physical or virtual environments that may be stressful with individuals having diverse personalities and work styles.
Must possess the ability to comply with Trinity Health policies and procedures.
Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
Must be able to perform some lifting and/or pushing/pulling up to 20 pounds if applicable.
Must be able to work with interruptions and perform detailed tasks.
If applicable, involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading.
Must be able to sit for long periods of time.
Telecommuting (working remotely), must be able to comply with Trinity Health’s and the Region/RHM Working Remote Policy.
Relevant Background Checks
Drug Screen
PPD / Tuberculosis Test
Reference Check
COVID Vaccination

Nice To Haves

If local, may include some travel to sites.
Must be able to travel to various Trinity Health sites (10%) as applicable.

Responsibilities

Accurately codes (ICD-10-CM) to the most appropriate level of specificity.
Follows current industry standards of ethical coding.
Recognizes and reports opportunities for documentation improvement to the Supervisor of Risk Adjustment Coding & Audit to develop and implement provider documentation improvement plans.
Ensures medical documentation and coding compliance with Federal, State and Private payer regulations.
Participates in continuing education activities to maintain their certification(s) and pertinent to areas of job responsibility.
Performs additional duties as assigned.
Adheres to St. Joseph’s Health’s confidentiality requirements as they relate to patient information.
Review and assigns accurate ICD-10-CM codes for diagnoses assigned in the EHR by the providers to claims being submitted for their services.
Using billing system work queues and natural language processing (NLP) tools to support addressing HCC codes for Risk Adjustment before a claim is submitted to payers.
Demonstrate a solid understanding of ICD-10-CM coding and medical terminology, Hierarchical Condition Category (HCC), and M.E.A.T standards.
Exercise thorough understanding of ICD-10-CM coding guidelines, payer regulations, compliance and reimbursement and the effects of coding in relation to risk adjustment payment models.
Identify coding discrepancies and work with risk adjustment auditor to communicate deficiencies to providers.