Will this role be fully remote?: Yes
Are there any specific locations the candidates should be in (i.e., do they need to live in IL):
Any approved states
What is the expected schedule (include dates/time/time zone): 7-4pm or 8-5pm local time M-F.
What are the day-to-day job duties?:
Abstract and review inpatient and outpatient medical records for (Hierarchical Condition Categories) HCCs to determine if the HCC is supported by the medical record documentation. Knowledge of ICD-9 ICD10 Official Coding Guidelines, AHA Coding Clinic, including Codling clinic clarifications for DOS year under review. CMS RADV Medical Reviewer Guidance (1/10/2020).
Top Skills Required:
Must have prior experience with CMS Contract Level Risk Adjustment Data Validation Audits (RADV) and HHS RADV audits and IPM audits.
Must have prior vendor coding review experience. Must have the ability to complete chart review production requirements.
Must be experienced in risk adjustment auditing. Must possess valid Certified Risk Adjustment Coder credential through AAPC.
Must have 5 years of risk adjustment auditing experience with a focus on CMS and HHS RADV reviews.
What additional IT equipment is required outside of a laptop/headset/mouse/keyboard (i.e., dual monitor & docking station or single monitor & connecting cables – note these will be billed back to Client at cost): Two monitors, one laptop, keyboard, mouse, headset.
Must have a Certified Risk Adjustment Coder certification (CRC) through AAPC or AHIMA
Will need to maintain a 95% or better coding accuracy performance
Adherence to coding accuracy and productivity policy and procedure regarding diagnosis code completeness and data entry in each coding accuracy review
Evaluate each medical record to ensure M.E.A.T. criteria support the existence of all submitted diagnosis codes
Review supplied medical records to determine if diagnosis codes mapping to HCCs meet CMS and HHS documentation guidelines
Must have intermediate/advanced Microsoft Excel skills
Well versed in ICD-10 Official Coding Guidelines, AHA Coding Clinic and any Coding Clinic Clarifications for DOS year under review
Should have prior CMS RADV contract level audit and HHS RADV coding experience
Should be familiar with Medicare Advantage and ACA lines of business
Summary:
Serves as the primary resource for medical coding updates and information.
Advises client on coding issues, provides in-depth research on new or unusual procedures, and makes recommendations when appropriate.
Provides support to the Claims and Provider Relations Departments.
Essential Functions:
Duties and Responsibilities:
Reviews and researches billed unlisted procedure codes to determine if a more specific code exists.
Supplies cover and pricing information to client Medical Director regarding unlisted codes.
Conducts meetings with state client to discuss procedure code coverage and ensures coding decisions are implemented.
Responsible for archiving all Procedure Code Workgroup (PCW) agendas, minutes, and related materials.
Maintains HIPAA reason and remark code lists and provides code updates to the HIPAA Code Workgroup, when necessary. Supports the Claims Department by working edit reports as assigned.
Provides Provider Relations with coding issues and updates to be shared with providers to ensure timely and accurate claim payment.
Maintains a library of code books and relevant resources to be available to personnel, when necessary.
Serves as a resource for the client and co-workers with question related to coding issues.
Knowledge/Skills/Abilities:
Proficient in MS Office Suite o Ability to work independently, with minimal supervision
Excellent verbal and written communication skills o Ability to abide by client’s policies
Ability to maintain attendance to support required quality and quantity of work
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
Required Education:
Bachelor’s Degree or equivalent experience
Required Experience:
5-7 years in professional coding experience, professional or hospital.
Knowledge of insurance claims processing.
Required Licensure/Certification: CRC (Certified risk adjustment coder certification through AAPC or AHIMA
Comments for Suppliers: : CRC (Certified risk adjustment coder certification through AAPC or AHIMA