Lead Hierarchical Condition Category (HCC) Coding Specialist

Company :

Job Description :

JOB SUMMARY

This job will deliver value to the Enhanced Community Care Management (ECCM) clinical risk assessment programs (MA and ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, CMS coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Conducts quality assurance (QA) review of internal coding team members, provides coding education to team, evaluates HCC coding questions and independently renders guidance on appropriate coding determinations. The incumbent supports RADV audits, specializing in performing second level review of HCC validation and research of outstanding HCCs; prepares documentation and coversheets for upload to regulatory body and/or independent auditor, and analyzes results. May also be responsible for high-priority and key strategic provider entities and/or anchor partners to analyze and evaluate coding trends; proactively identify issues and present solutions to internal leadership and external entities; leads activities with provider entities. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and/or compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding. Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums. May also complete analysis on provider coding trends create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis.

ESSENTIAL RESPONSIBILITIES

• Conducts Quality Assurance (QA) reviews on internal coders, at minimum, bimonthly for coder score and education/feedback to coder.Monitors the QA Questions Queue, independently researches questions using appropriate sources, including AHA Coding Clinic®, and responds to questions from all coding teams (retrospective, prospective, and audit).Publishes QA question & responses and presents education on monthly team meetings.Conducts Quality Assurance reviews on vendors monthly or per contract SLA.Provides education/feedback to the vendor.Conducts quality reviews of high-risk and incremental HCCs and applies expertise to analyze documentation and mitigate risk to the organization. May support external vendor quality review(s) to measure coding accuracy, prepare and report findings, and monitor accuracy. Collaborates with team members to optimize data collection and review, provider education and outreach, and coding quality. (20%)
• Plays an integral role in the completion of all Government Audits, including Improper Payment Measure (IPM), CON-RADV, ACA-RADV, and Office of Inspector General (OIG), as applicable.Applies extensive clinical and coding knowledge and abilities, independently conducts coding research, aligns all aspects of audit, including coding adjudication and rebuttals with audit vendor, obtains provider attestations, identifies & obtains missing medical records, compares audit results to claims, and thoroughly reviews all in-house charts in chart repository for validation of audit.Prepares documentation and coversheets for upload to regulatory body or independent auditor. (20%)
• Responsible for high priority and key strategic provider entities and/or anchor partners to analyze and evaluate coding trends; proactively identify issues and present solutions to internal leadership and external entities.Leads engagement activities with the provider entity.Provides support for entity and acts as liaison between all provider facing team. Conducts data analyses from medical record reviews; proactively summarizes opportunities to enhance provider documentation to improve coding accuracy and thorough capture of members’ chronic health conditions. Completes analytics on providers and/or provider group coding trends and creates and delivers externally facing presentations to provider documentation and accuracy, act as the point person for the provider office for any questions and additional trainings, as needed. (20%)
• Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures to guide HCC coding decision making. Achieves and maintains coding productivity and quality accuracy metrics set by the management team. (10%)
• Executes assigned projects in accordance with project plans; monitors progress and makes adjustment as necessary to ensure successful completion. Participates on ad-hoc projects per the direction of leadership to address the needs of the department. (10%)
• Develops and presents process improvement and training initiatives to improve efficiency and accuracy of departmental coding practices.Regularly presents and contributes to coding education meetings and Annual Coding Summit.Adapts presentation style to audience; provides constructive feedback; presents in-person, virtually and/or by webinar. (10%)
• Mentors new hires and coworkers on CMS and Highmark coding guidelines and contributes to onboarding and training material development and enhancement. (10%)
• Other duties as assigned or requested.

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EDUCATION

Required

• Associate's degree in medical billing/coding, health insurance, healthcare or related field, or relevant experience and/or education as determined by the company in lieu of bachelor's degree

Preferred

• Bachelor's degree in medical billing/coding, health insurance, healthcare or related field

EXPERIENCE

Required

• 5 years of HCC risk adjustment coding experience

Preferred

• Previous experience in an auditing or CDI-focused coding role.
• Experience working directly with clinical providers to improve documentation.
• 7 years of HCC risk adjustment coding experience
• 3 years of RADV audit experience
• 3 years of Coding QA experience
• 3 years of LPN or RN experience
• 1 years of Management or leadership

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LICENSES or CERTIFICATIONS

Required (any of the following)

• Certified Professional Coder (CPC)
• Certified Risk Coder (CRC)
• Certified Coding Specialist (CCS)
• Registered Health Information Technician (RHIT)

Preferred

• Certified Risk Adjustment Coder (CRC) from a recognized organization (e.g., AAPC, AHIMA).
• Certified Documentation Expert Outpatient (CDEO), Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) is highly preferred.

SKILLS

• Critical Thinking
• Attention to Detail
• Strong Verbal and Written Communication Skills, including Presentation Skills
• Ability to objectively analyze facts and form judgments
• Ability to handle manage projects to a successful outcome
• Strong interpersonal skills
• Ability to identify and resolve problems
• Ability to work in a fast-paced, collaborative environment with minimal supervision
• Extensive knowledge of medical terminology and ability to research coding-related questions
• Strong clinical knowledge related to chronic illness diagnosis, treatment, and management
• Microsoft Office Suite Proficient - MS Word, Excel, Outlook, PowerPoint, MS365 and Teams

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Remote Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum: