Quality Assurance Coder/Auditor
Blue Cross Blue Shield of ArizonaAbout the role
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
Onsite: daily onsite requirement based on the essential functions of the job
Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building
Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB
The Quality Assurance Coder/Auditor will develop a risk mitigation and provider education program. On a regular basis, Coder/Auditor will educate primary care providers and their staff on their historical diagnoses/coding error trends, accurate completion of medical record documentation, and at-risk code identification and risk mitigation, . This includes the review, analysis, and recommended coding based on medical and clinical diagnoses, procedures, injuries, or illnesses contained in medical records and supporting documentation.
The Quality Assurance Coder/Auditor will perform risk mitigation analysis using available vendor tools to identify at-risk single occurrence of HCCs and OIG targets. Deletions will be submitted for unsupported/invalid diagnoses. This analysis combined with QA findings and EDPS claims errors will drive the content and audience for provider education.
The Quality Assurance Coder/Auditor will perform medical record reviews and abstract codes - to the highest specificity effectively from medical records based on the documentation provided. Coder/Auditor is responsible for ensuring diagnosis codes selected come from a face-to-face visit with a valid Risk Adjustable provider. Coder/Auditor will perform QA for vendors and other submitters of supplemental HCC data and provide educational feedback relevant to same.
REQUIRED QUALIFICATIONS
Required Work Experience
- 5 years of professional coding experience, with at least 3 years of HCC coding experience, and 2 years of HCC auditing experience. Advanced knowledge of coding guidelines
Required Education
- High School Diploma or GED in general field of study
Required Licenses
- N/A
Required Certifications
- Certified Coding Specialist – Physician Based (CCS-P), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Outpatient Coding (COC) credential
PREFERRED QUALIFICATIONS
Preferred Work Experience
- 5 years of Medicare Advantage health plan experience
- 5 years of experience with HEDIS measures and/or the CMS Star Program
Preferred Education
- N/A
Preferred Licenses
- Clinical training (Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant)
- Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (RHIA)
Preferred Certifications
- Certified Documentation Expert Outpatient (CDEO)Certified Professional Medical Auditor (CPMA)
ESSENTIAL JOB FUNCTIOSN AND RESPONSIBILITIES
- Demonstrate comprehensive understanding of HCC Coding rules, regulati
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