Quality, Education & Coding Specialist

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization. 
• Create an equitable work environment. 

About the Role

Quality, Education & Coding Specialist works collaboratively with clinic and providers for enhancements, training and education for risk adjustment documentation and performs medical record reviews in accordance with HEDIS technical specifications. This position requires demonstrated knowledge, skill and ability to educate, train and advise clinical staff for process improvements.

This position is also responsible for performing quality medical record reviews, assisting providers and staff in the improvement of clinical documentation and workflows, identifying trends and gaps in care, maintaining accurate records of review activities, ensures all data submitted to the health plan meets HEDIS technical specifications for medical records.

To be successful in this role, you:

• Possess an Associate’s Degree or an equivalent combination of education and highly relevant experience required.
• Have current Coding Certification (CPC, CPC-P, CPC-H, CPC-I, CRC, CCS, RHIT, RHIA etc.) through AAPC and/or AHIMA required.
• Have current, unrestricted license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) required.
• Possess a minimum of three years coding experience with specific knowledge of Medicare and Commercial Risk Adjustment such as Hierarchical Condition category (HCC) and/or Chronic Illness and Disability Payment System (CDPS).
• And a minimum of three years working with HEDIS data including chart review/collection. HEDIS, QRS, or STARs experience.
• Have experience in Health Plan Risk Adjustment Data Validation Audit (RADV) experience is preferred.
• Have clinical knowledge related to chronic illness diagnosis, treatment and management.
• Have experience working with clinical staff for process improvement; ability to provide education and coaching to clinic staff.
• Have experience with Microsoft Office applications, including Word, Excel and PowerPoint.

Essential functions and Roles and Responsibilities:

• Collaborate, educate and train clinical support staff and providers on risk adjustment documentation and workflows specific to HCC and CDPS models.
• Ensure compliance with internal coding guidelines, department policies, and CMS risk adjustment coding guidelines, rules and regulations. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Audit provider and vendor documentation of ICD-10 codes to ensure adherence with risk adjustment guidelines.
• Perform root cause analysis to identify issues that may contribute to coding, documentation, claims or other revenue cycle deficiencies.
• Provide coding support, education and training related to, quality of documentation, level of service and diagnosis coding consistent with established coding guidelines and standards to providers and staff.
• Provide real-time support for clinical care and HEDIS/Star teams for annual submission.
• Maintaining an abstraction proficiency rate of 95% by correctly reading, interpreting, and abstracting various components of the medical record such as notes, consultations, medication forms, treatment plans, health history, interval history, and past history.
• Maintaining productivity level of a minimum of 50 chases/charts per defined period according to policy.
• Utilizing various software applications to support department operations and accurately entering the results of chart audits into the database.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Applied understanding of principles of reimbursement based on risk adjustment model(s) including CMS Hierarchical Condition Categories (HCCs) and Chronic Illness and Disability Payment System (CDPS).
• Knowledge of acceptable medical record standards and criteria in the context of risk adjustment data validation (RADV).
• Advanced, applied knowledge of ICD-CM codes, coding conventions and coding guidelines.
• Proficiency with comp