Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Capital BlueCross Government Programs Risk Adjustment coding position is a unique position that combines knowledge and experience in risk adjustment coding, Medicare and Government regulations, Medicare Advantage risk adjustment model, HHS ACA risk adjustment models, and RADV and HRADV experience.

Responsibilities and Qualifications

• Perform comprehensive review and oversight of medical records for Risk Adjustment compliance keeping with CMS and departmental guidelines with a 95% accuracy rate
• Offer suggestions and assistance for improvement in departmental processes & other duties as assigned
• Collaborates with a variety of internal and external clients, including health care executives, physicians, provider office personnel, and payer representatives from various health plans to streamline and optimize accurate diagnosis code capture.
• Maintains responsibility for conducting clinical chart and patient billing audits for the purpose of
• Identifying and validating reported diagnoses for Medicare/Medicare Advantage and ACO health plan members.
• Reviews medical records and billing history to determine if specific disease conditions were correctly billed and documented.
• Adheres to all official coding rules and CMS guidelines for risk adjustment, and ensures accuracy,
• Completeness, specificity and appropriateness of diagnosis information.
• Assists with the completion of HEDIS chart reviews and facilitates the accurate and timely reporting of quality

Skills:

• Strong analytical skills.
• Ability to problem solve.
• Detail oriented with high degree of accuracy.
• Ability to exercise discretion in handling confidential member information.
• Strong commitment to customer service and understanding and responding to customer needs within specific timeframes.
• Valid PA driver’s license and access to a reliable vehicle.
• Proficiency with Microsoft Word, Excel and PowerPoint or comparable software required.
• Maintains established work production standards
• Assumes responsibility for professional growth and development
• Ability to work independently in a time-oriented environment
• Participates in professional healthcare and community associations to keep abreast of current healthcare trends is expected

Experience:

• Prior HCC/HHS experience with Medicare Risk Adjustment with 3 years’ experience in medical coding.
• Familiarity with the CMS Medicare risk algorithm (CMS HCC) and the ACA risk algorithms (HHS HCC)
• Direct experience speaking with providers is preferred
• Active CRC credentials is required

Education and Certifications:

• High School Diploma or GED
• Coding education including understanding of proper guidelines and usage of ICD-10-CM, CPT and HCPCS
• RHIT - Registered Health Information Technologist, CPC-P - Certified Professional Coder (Physician) OR CCS-P - Certified Coding Specialist (Physician), AND CRC-Certified Risk Adjustment Coding Credential required.
• Nursing licensure is considered a bonus.

Work Environment:

• Ability to operate a personal computer (PC), including proficiency in Microsoft Office Suite.
• Demonstrated ability to interact with other departments. Demonstrates openness, flexibility, problem solving, patience, and tact when dealing with providers, members and staff. Knowledge of risk adjustment principles and coding updates.
• Excellent written and oral communication skills.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

Travel Requirements:

• The ability to travel to provider and member locations using reliable source of transporation.

Other:

• Key Interfaces: Physicians, members, caregivers, health system staff, Government officials, Capital Blue Cross staff and management
• Ability to work within a matrix-configured work environment
• Highly regulated industry.
• High visibility and responsibility.
• Strategically important position and functions with significant membership, revenue, and compliance risks.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.