The Revenue Optimization coder will work closely with the VP of Strategy and Innovation and the rest of the Revenue Optimization team on all areas of efficiency and optimization of funds related to reimbursement, payments, and member care including but not limited to:

· Responsibilities related to Medicare Risk adjustment processes

o Review of encounter report to identify priority claims and providers for review

o Review of medical records and claims for opportunities for correct coding; codes that map to HCC codes

o Education of providers on coding opportunities and medical record documentation

· High level oversight of claims being received and paid each claim cycle

o Review of claims by provider tracking trends and over-billing by providers and provider types

o Review of hospital, skilled nursing facility, emergency department, and outpatient surgery claims for opportunities for correct coding of claims

o Communication with providers to educate on correct coding and billing and appropriate utilization

· Assistance as needed with oversight and tracking of MLTC quality items

o Education of care management department on items with opportunities for increased quality ratings

· Assistance as needed with oversight and tracking of Medicare HEDIS items

o Education of multiple company departments on techniques for maximizing HEDIS ratings

Essential Responsibilities:

· Work within a multidisciplinary team to develop processes for tracking data and identifying efficiencies and solutions for multiple items affecting revenue optimization

· Works to meet specific goals as developed by team on projects and initiatives listed

· Works with consultants and supervisor to develop and implement processes specific to MA risk adjustment optimization

· Reviews member charts to identify gaps in documentation, works with physicians and physician groups to educate them on processes and correct documentation gaps

· Follows up on documentation and encounter submissions to ensure correct coding and documentation

· Has the ability to make decisions that are financially prudent, highly ethical, in compliance with all governing regulations, and demonstrate a commitment to our members welfare and well-being

· Engages in ongoing education as recommended and offered by the company

· Participates in quality improvement initiatives

· Other duties as assigned

Specific Knowledge, Skills, and Abilities:

· Ability to read and interpret documents, identify areas of coding gaps. Ability to speak effectively with physicians and employees of the agency.

· Ability to identify areas of over or under utilization and work with team and physician groups to develop processes to avoid

· Ability to work with team on development of processes for right-coding, appropriate utilization, and closing gaps in care

Required Education, Experience, and Licenses:

• Certified coder
• 1-2 years satisfactory experience in Managed Care, desired.

Job Type: Full-time

Pay: $75,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Application Question(s):

• Experience in Risk Adjustment HCC Coding?

Ability to Relocate:

• Spring Valley, NY 10977: Relocate before starting work (Required)

Work Location: In person