Risk Adjustment Coder/Analyst

I. General Summary

Responsible for performing medical record diagnosis code abstraction based on clinical documentation, ICD-10-CM Official Guidelines for Coding and Reporting, AHA Coding Clinic Guidance, CMS program guidance, and in accordance with applicable federal and state, laws, rules, regulations, and UMMS policies and procedures. Apply guidance provided for the medical records code abstraction for the following programs, Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, Commercial IVA (Initial Validation Audit), and Medicare RADV (Risk Adjustment Data Validation) and Medicaid. Work collaboratively with internal departments and external stakeholders. Work is performed under limited supervision. Direct report to the Senior Manager, Risk Adjustment.

II. Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Perform code abstraction of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation.
• Identify diagnosis and chart level impairments and documentation improvement opportunities for provider education.
• Assist coding leadership by making recommendations for process improvements to further enhance coding goals and outcomes.
• Maintain knowledge of and ensure compliance with ICD-10-CM codes, CMS documentation requirements, and applicable federal and state, laws, rules and regulations.
• Consistently maintain a minimum of 95% accuracy on coding quality audits.
• Meet minimum productivity requirements as outlined by the project terms.
• Assist with individual and/or group education with healthcare providers as directed by the Senior Manager, Risk Adjustment.
• Participate in developing, maintaining and meeting key performance indicators as defined in the Risk Adjustment Project Plan annually.
• Maintain and update the Risk Adjustment Project Plan annually.
• Stay abreast of trends and regulations to ensure effectiveness and compliance of the Risk Adjustment program.
• Assist with quality assurance tools and processes.
• Establish an understanding of the PHSO Risk Adjustment Project Plan and its interdependency on the PHSO Strategic Plan.
• Participate and assist with preparation for meetings including but not limited to internal PHSO, payer, practice, etc.
• Establish and maintain collaborative relationships with all levels of leadership, staff, and vendors.
• Perform other duties as assigned.

Requirements

III. Education and Experience

• Associate’s degree in healthcare, or related field required. Bachelor’s degree preferred.
• 3+ years’ experience in Medicare or Medicaid Risk Adjustment models (CMS-HCC, HHS-HCC, and DxCG risk adjustment methodology.
• 3+ years’ experience in the outpatient care setting required.
• Experience with EPIC, Cerner and/or NextGen.
• Certified Risk Coder certification from AAPC required.
• One of the following certifications from AHIMA or AAPC preferred: Certified Professional Coder (CPC), Certified Coding Specialist (CCS or CCS-P).

IV. Knowledge, Skills, and Abilities

• Working knowledge of risk adjustment coding/billing/documentation workflows.
• Working knowledge of healthcare metrics.
• Advanced knowledge of the Affordable Care Act and its impact on Total Cost of Care and Value Based Care.
• Demonstrated ability to think strategically, understand functional structures, manage project work, and generate innovative and practical solutions to complex or unusual problems.
• Advanced skill running, interpreting, and creating reports in Excel SharePoint, etc.
• Advanced customer service and client facing skills.
• Advanced skill developing and maintaining collaborative working relationships with all levels of leadership, team members and vendors.
• Self-motivated individual who can excel with little supervision and the proven ability to be successful in a fast paced, dynamic environment.
• Advanced skill presenting findings, conclusions, alternatives, and information clearly and concisely at all levels within the organization.
• Ability to analyze, compare, contrast, and validate work with keen attention to detail.
• Advanced analytical, critical thinking, planning, organizational, and problem-solving skills.
• Keen sense of personal responsibility and accountability for delivering high quality work.
• Advanced verbal, written, and interpersonal communication skills.
• Advanced skill in the use of Microsoft Office Suite (e.g., Word, Excel, PowerPoint.).

V. Working Conditions

• Weekend, shift work, holiday, on-call, and may require work beyond normal tour of duty to complete projects, meet deadlines, or respond to emergencies.
• Working hours may require early or late hours (outside of traditional business hours) to meet program goals and support clinical schedules.
• Work may include regular travel to and from the various affiliated institutions within the Medical System and Quality Care Network

Additional information

All your information will be kept confidential according to EEO guidelines.

This is a fully remote position.