Full time
Day Shift
GENERAL SUMMARY AND PURPOSE:
The Risk Adjustment Coding Specialist will be responsible for the creation and/or compilation of educational materials and conducting coding and documentation education with providers, the clinic care team and coding/billing staff The Risk Adjustment Coding Specialist may also conduct medical record audits for risk adjustment and core quality measures and assist with other performance improvement initiatives that promote the success of Advanced Payment Model (APM) contracts.
The position is responsible to work with all applicable payer partners for varying arrangements spanning across Medicare, Medicare Advantage, Commercial, QHP and Medicaid, and will leverage data and reports to maximize clinical condition documentation (CCD), and will become familiar with risk adjustment methodologies as applicable (HCC/RAF, HHS, MARA, Johns Hopkins, etc.)
The Risk Adjustment Coding Specialist will provide insights and direct contributions to the development of analytics and reporting to enhance providers' ability to document and code to the highest level of specificity and improve coding and recapture rates as is clinically appropriate. The role will maintain strict confidentiality of all data and information.
The Risk Adjustment Coding Specialist will develop and maintain collaborative relationships with internal and external partners to ensure effective, results-oriented project outcomes.
SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:
High school diploma or equivalent required. Associates/Bachelor's Degree or some college preferred. AAPC or AHIMA coding credential required. Certified Risk Adjustment Coder (CRC) required. Required Experience:
Minimum of 2 years of experience working in risk adjustment coding in a medical practice, network or payer setting using electronic health records (EHR). Chart auditing experience preferred.
Minimum of 4 years coding experience.
ESSENTIAL FUNCTIONS:
Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. Develops and implements annual coding and documentation chart auditing process to include appropriate team members to ensure compliance and timeliness of completion to meet payer deadlines for submission.
Serves as HCC subject matter expert and network resource for primary care, specialty practices, and internal coding colleagues Develops and implements risk adjustment education programs to support providers and staff to increase knowledge of quality and CMS HCC, HHS and MARA Risk Adjustment-driven payment methodologies and the importance of proper chart documentation of procedures and medical conditions. Conducts focused quality performance and risk adjustment audits (Alliance) or pre-visit planning (Medical Group) in physician offices either via on-site review or remote login of databases, such as clinical registries and electronic medical records. Evaluate individual provider documentation practices to identify areas for improvement in quality and specificity.
Initiate both group and one-on-one training and/or recommendations for additional areas of training. Document and report provider and practice engagement to leadership team. Reviews payer data to identify coding opportunities. Validates accuracy of HEDIS/coding data and inputs/uploads data into payer portals including HQPAF forms.
Monitors HEDIS/5 Star and risk adjustment progress across the network. Review high risk/high cost reports to identify patients appropriate for Care Management services (Alliance). Supports the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) chart audit process January through March. Maintains strict confidentiality of all data and information. Responsible for scheduling meetings to include physician peer review activities.
Extensive knowledge of ICD-9-CM, ICD-10-CM, CPT and HCPC Coding Guidelines. Extensive knowledge of CMS Hierarchical Condition Categories (HCC), HHS/QHP and commercial risk adjustment methodologies. Demonstrate knowledge of medical terminology, medical abbreviations, anatomy and physiology, pharmacology and disease processes. Electronic health record (EHR) experience/ability to navigate different EHR's.
Excellent written and oral communication skills including presentation skills and ability to analyze, summarize and concisely report medical utilization, coding and documentation audit results and outcomes of other quality and risk adjustment projects. Ability to affect change within a provider or practice workflow. Intermediate Microsoft Office (Excel, Word, Outlook, PowerPoint) skills required to perform data management, analysis and prepare reports.
Demonstrate customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies and patients. Proven ability to work independently with attention to accuracy and consistency of information obtained and recorded in development and completion of large and complex quality and risk adjustment projects.
Demonstrates ability to function effectively in a fluid, dynamic and rapidly changing environment. Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analytic skills, decision-making, priority setting, work delegation and work organization.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
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