Risk Adjustment Consultant

Tufts Medicine•Tufts Medicine Integrated Network, MA

21h•$72,372 - $90,465•Remote

About The Position

Under the director of the Director, Risk Adjustment Operations, performs accurate and timely reviews and validations of Medicare, Medicaid, Commercial HCCs and DxCG’s through medical record reviews. Reviews provider documentation for ICD-10-CM codes to verify that coding meets both established coding standards as well as CMS and Commercial Risk Adjustment guidelines. This position has extensive knowledge of overall ICD-10-CM coding standards, as well as lead efforts to evaluate the HCC/DxCG coding practices and provide analyses and recommendations to improve overall provider documentation as it pertains to coding and risk adjustment guidelines. Reviews medical records to determine if diagnostic codes (ICD-10-CM) as well as Current Procedural Terminology codes (CPT) are accurately reflecting the provider documentation. Summarizes findings for internal and external parties and will provide provider education when necessary.

Requirements

Certified Risk Adjustment Coder (CRC) OR must obtain within first 12 months of employment
Two (2) years of outpatient billing, coding, and risk adjustment experience.

Nice To Haves

Associate’s degree.
Certified Risk Adjustment Coder (CRC) highly preferred.
Two (2) years of outpatient billing, coding, risk adjustment, and primary care adult medicine experience.

Responsibilities

Performs ongoing audit of medical records for our LCO groups and network providers to ensure diagnosis and CPT coding accuracy.
Performs medical record audits to determine coding accuracy to coding standards in correlation to CMS and DxCG regulations and guidelines.
Evaluates medical records for authorized providers, face-to-face CPT codes, and appropriate written and electronic signatures as well as other technical requirements.
Summarizes and interprets audit findings for Director Risk Adjustment Operations/NEQCA Leadership; tracks audit results over time, identifies trends, and recommends corrective actions.
Collaborates with Director Risk Adjustment Operations/NEQCA staff and vendors to identify and submit coding adjustments, as needed.
Provides education and feedback to physicians on a regular basis in regard to Risk Adjustment Coding guidelines (HCC/DxCG), as well as ICD-10-CM Guidelines and regular coding requirements.
Maintains a current and strong understanding of coding rules and CMS guidelines in the outpatient settings.
Interprets and summarizes coding guidelines and CMS regulations for TMCPO/NEQCA leadership.
Incorporates changes to guidelines and regulations into audit practice.
Researches and resolves coding and risk adjustment regulatory issues.
Works retrospective/concurrent audit reports to close diagnosis gaps within our risk adjustment contracts.
Performs pre-visit chart reviews and provider outreach.
Provides coding expertise to evaluate internal coding program opportunities.
Provides LCO and network providers trainings and education as needed.
Summarizes and presents recommendations to key internal staff.
Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action.