Description

Primarily responsible for overseeing and facilitating quality assurance audits for providers and internal coders. The audits will be used to set department goals and objectives, to identify deficiencies or process improvements, and to ensure compliance with state and federal guidelines. Focus will include the review of HEDIS performance measures and ensuring submitted conditions are fully supported by clinical documentation and are being coding to the highest specificity and accuracy. As part of the population health team the HCC Risk Adjustment Coder will work in different capacities within the department to assist with establishing accurate risk scores for our patients.

Requirements

• Perform clinical validation audits and interpretation of medical documentation to capture all Medicare Risk codes 
• Provide formal report(s) on audit findings; create and generate reports with summary of findings
• Evaluate, track, and monitor risk adjustment data, address progress towards optimal performance within payor portals, Juxly, and other population health tools.
• Analyze findings of completed audits to determine coding error trends; present recommendations for process improvements to prevent reoccurrence
• Participate in developing HCC category training and resource materials using evidenced-based criteria and guidelines
• Perform initial audits for new practices and provide input on how Providers can best be supported
• Perform ongoing prospective and retrospective chart reviews
• Assist with meeting quality improvement and risk management targets
• Maintain an up-to-date knowledge of all risk adjustment programs and the quality metrics in which the company participates with health plans and other payer incentive programs that may develop over time
• Ensure Juxly and other population health platforms are continuously updated to meet the needs of the risk adjustment program
• Participate in various special projects stemming from results of previous audits and report any improvement or nonengagement
• Assist Coding leadership by making recommendations for process improvements to further enhance coding quality goals and outcomes
• Work directly with Leadership on the continued development and enhancement of risk adjustment programs intended to improve the capture of HCC chronic conditions
• Stay abreast of primary care practice standards, e.g., STARS, HEDIS, and RAF
• Maintain current knowledge of ICD-10-CM codes, CMS documentation requirements, and federal and state regulations; research regulatory guidelines for supporting documentation
• Participate in departmental and organizational quality management activities

Required Education, Knowledge & Experience:

• High school diploma or GED equivalent
• Minimum of three (3) years of hands-on experience with responsibility for HCC coding and auditing
• CRC or CPC required
• Proven knowledge of quality performance measures and risk adjustment methodology
• Experience with clinical documentation and risk adjustment documentation review
• Successful record of managing multiple projects with demonstrated ability to work independently in matrixed and rapidly changing environments
• Excellent verbal, written, and interpersonal communication skills; highly collaborative team approach to work
• Proficiency with Microsoft Office applications with expertise in Excel, and using web-based technologies

Physical & Mental Requirements:

• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Ability to travel to multiple locations to support business needs as required