JOB SUMMARY:

Responsible for the review, analysis, reporting and follow-up of risk adjustment and clinical coding functions to support the accurate representation of the member's clinical health status as well as the accuracy of internal systems to support clinical decisions. This role works collaboratively with multiple internal departments as well as with external providers.

KEY RESPONSIBILITIES:

* Serve as clinical coding resource across the CommunityCare Health Network Division in support of both ongoing and future coding related initiatives.

* 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.

* For Risk Adjustment Validation Audits (RADV), conduct chart review of inpatient and outpatient medical records for Hierarchal Condition Category (HCC) coding. Summarizes audit findings and recommendations for coding and/or documentation improvement.

* Evaluate Medicare Wellness Visit documentation for accuracy and completeness in addressing gaps in care and expiring HCC's. Present findings to providers on a regularly scheduled basis.

* Evaluate/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.

* Engage with other Health Network Division Department leaders for opportunities to optimize clinical documentation at the point of care delivery. Provide measurable, actionable solutions for best practices to improve documentation and coding accuracy. Develop a feedback loop for provider query and education. This will involve collaborative work with owner and non-owner providers.

* Analyze the in-home assessment program for opportunities to follow-up on members who decline the assessment or do not schedule care.

* Support work/data from the Benefits Interpretation Committee (BIC) and the quarterly coding review workgroup.

* Support clinical coding needs of ASO (self-insured employers) marketing, claims and configuration departments, and preventative services list maintenance.

* Work in collaboration with company fraud, waste, and abuse program on issues with specific providers or services as may arise.

QUALIFICATIONS:

* Knowledge of risk adjustment payment models and risk adjustment coding preferred

* Familiarity with State and federal regulations governing healthcare

* Medicare Advantage and /or medical practice experience preferred

* Proficient in Microsoft Excel

* Successful completion of Health Care Sanctions background check

* Excellent verbal and written communication skills

* Ability to work independently under stringent deadlines

EDUCATION/EXPERIENCE:

* Coding certification nationally recognized by AAPC or AHIMA required

* Bachelor's degree preferred or equivalent experience

* Three (3) years relevant professional experience with medical coding (ICD 10-CM, CPT, HCPCS)

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

Other details

* Job Family Commercial

* Pay Type Salary

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* Tulsa, OK, USA