Lead Hierarchical Condition Category (HCC) Coding Specialist - (Remote)

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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 pro