Risk Adjustment Medical Coder

Pay Range:

Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people.

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self.
It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

We’re dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

Perform medical record reviews of Medicare Advantage members to ensure proper medical diagnoses are being submitted to Centers for Medicare & Medicaid Services (CMS) for accurate risk adjustment payments. Perform data validation of collected medical codes from both outpatient and inpatient settings. Assist with the review and perform on-site and remote retrieval of medical records for internal and external audits.

What you’ll do:

• Perform risk adjustment data validation of Medicare Advantage member charts including outpatient and inpatient services provided by physicians. Ensure primary and secondary diagnoses are reported in accordance with CMS payment guidelines to ensure Plan receives accurate risk adjustment payments. Achieve team annual recovery goal targets.

• Detect trends in documentation to identify at-risk claims and documentation errors for provider education. Coordinate with provider education department in order to schedule physician on-site and remote chart reviews with physicians and/or office staff in a professional manner.

• Provide recommendations to physicians to incorporate and promote industry best practices. Distribute informational/educational correspondence as appropriate.

• Perform audits of claims data to flag unsupported diagnoses for deletion to mitigate audit risks.

• Identify errors through data validation; facilitate remediation with internal business areas. Assist and retrieve member information to correct informational errors as necessary.

• Review claims data to validate member risk scores; gather documentation for CMS appeals if risk scores are challenged.

• Analyze audit results to and be able to interpret those to leadership to inform coding policies.

• Use NLP (Natural Language Processing) software to audit records, identifying codes to submit for capture and codes eligible for deletion.

• Maintain expert industry knowledge as related to the risk adjuster process and coding regulations. Actively participate in physician coding review discussions.

• Participate in the retrieval and review of medical documentation relevant to risk adjuster activity for internal and external audits. Serve as subject matter expert on coding initiatives and member chart review.

• Participate in department initiatives and projects.

• Perform other duties as assigned.

What you need to succeed:

• Certified Professional Coder (CPC, CPC-H), or Certified Coding Specialist (CCS) designation; or an equivalent combination of education and experience

• Three to five years of experience in medical claims review or claims processing

• Three to five years of experience in quantitative or statistical analysis (preferably in health care)

• Proven analytic experience using Microsoft Excel, database query capabilities and ability to evaluate data at various levels of detail

• Proficiency in ICD-9/10-CM medical coding

• Advanced analytical skills, with the ability to interpret and synthesize complex data sets

• Good business acumen and political savvy

• Knowledge of business process improvement techniques and strategies

• Excellent verbal and written communications skills

• Negotiation skills

• Presentation skills

• Decision-making skills

• Good problem-solving skills

• Ability to interface with employees at all levels

• Ability to effectively navigate ambiguous situations with limited direction

• Excellent organizational skills and ability to successfully prioritize multiple tasks

• Ability to handle multiple priorities/projects

The Extras:

• Registered Nurse (RN)

• Bachelor’s degree

• Knowledge of ICD-9-CM, ICD-10-CM and CPT coding

• Professional designations (e.g. CPC-H, or CPC-P, CRC)

• Knowledge of Hierarchical Condition Category (HCC) payment model and American Hospital Association Official Coding Guidelines

• Familiarity with hospital contract reimbursement
  

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office : onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
  
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.