Sr Risk Adjustment 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

The Senior Risk Adjustment Coding Specialist is responsible for coordinating, monitoring, and performing documentation and coding audits for risk adjustment. This role supports developing and performing provider education, assists Risk Adjustment Coding Manager with identifying opportunities for process improvement, performs overread and peer review of other coding team member output, and supports determining work assignment distribution.

To be successful in this role, you:

• Are committed to advancing diversity, equity, and inclusion across CHPW.
• Have a minimum of 5 years of experience in medical coding, preferably in a health plan setting.
• Are a Certified Risk Adjusted Coder (CRC).
• Are a certified American Health Information Management (AHIMA) Certified Coding Specialist (CCS), or American Academy of Professional Coder (AAPC) Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H) Coding Certificate.
• Have proficiency in Microsoft Office applications such as Outlook, Word, Excel.

Essential functions and Roles and Responsibilities:

• Support updating and maintaining CHPW coding guidelines to reflect changes of the ICD-10 CM Official Guidelines for Coding and Reporting, new AHA Coding Clinic Advices and new guidance from Center for Medicare & Medicaid Services (CMS). Interpret changes in the external regulatory environment and support modifying CHPW policies accordingly in coordination with Risk Adjustment Coding Manager and Risk Adjustment Program Manager. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Update and distribute provider feedback reports periodically / as needed for identifying provider performance trends and participate in creating materials. Share all significant audit findings including trends and associated recommendations (e.g., training, oversight, monitoring, process flow changes, documentation, and coding education) specific to internal departments, coding vendors, and others.
• Coordinate with the Risk Adjustment Coding Manager to prioritize tasks of other full time and/or temporary coding staff. Support overread and validation of other coders documentation performance. 
• Lead the risk adjustment coding and documentation quality assurance process and oversee the workflow of the retrospective coding review.
• Present findings via verbal and written updates to internal and external audiences including peer to peer, department leadership (Director, Senior Director, Vice President) and reporting to provider and clinical teams, and vendor support teams.
• Identify and implement best practices and Quality Assurance process improvement opportunities.
• Monitor and comply with internal coding guidelines, department policies, and CMS risk adjustment guidelines, rules, and regulations. Stay current with changes in the external regulatory environment and modify CHPW policies accordingly.
• Ensure timely review of regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Support chart audit processes, including audit provider and vendor documentation of ICD-9 and ICD-10 codes to ensure adherence with Center for Medicare & Medicaid Services (CMS) risk adjustment guidelines, and act as a liaison between internal departments and external entities on regulatory data validation audits (including CMS RADV and HHS RADV).
• Perform root cause analysis to identify issues that may contribute to coding and documentation deficiencies.
• Perform internal and external coding quality reviews to validate correct ICD-10-CM code assignments.
• 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:

• Knowledge of risk adjustment coding guidelines, regulations, and industry trends and best practices and technology advancements.
• Knowledge of CMS Hierarchical Condition Categories (HCCs) and HHS-HCC models.
• Knowledge o