JOB SUMMARY

The Risk Adjustment Coding Specialist supports HealthTeam Advantage mission of improving the health and well-being of our communities through a commitment to personalized service, quality, and enhanced care experiences by identifying actual health conditions of our members while maintaining core values of integrity, quality, service, people, and patient safety.

The Risk Adjustment Coding Specialist will perform and support risk adjustment activities in accordance to both the Centers for Medicare and Medicaid (CMS) rules and regulations and the American Hospital Association (AHA) documentation guidelines for the proper ICD-10-CM code assignment.

In addition, the Risk Adjustment Coding Specialist will perform prospective and retrospective chart reviews of both inpatient and outpatient services for capture of compliant Hierarchal Condition Categories (HCC). The Risk Adjustment Coding Specialist will also responsible for record retrieval, Risk Adjustment Data Validation (RADV) audits, and all other Risk Adjustment Compliant activities. The Risk Adjustment Coding Specialist will partner and assist with the Risk Adjustment Nurse Coding Specialist and the Risk Adjustment Coding and Documentation Specialist as needed.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This position must be able to: ****

Medical Record Review:

• Conduct and/or assist with prospective/retrospective medical record review audits evaluating medical record documentation to ensure hierarchical condition category (HCC) coding is accurately supported/captured HealthTeam Advantage by review of coding, medical record documentation and billed claims.
• Responsible for the manual chart retrieval process for internal coding activities such as but not limited to internal audits, assisting with vendor retrieval, and RADV.
• Collaborate with Provider Services when needed to assist with record retrieval.

Vendor Coding Review:

• Perform vendor quality oversight audits by auditing a sample of targeted charts to ensure coding quality in accordance with vendor’s contract.
• Assist with tracking coding vendor audit results.
• Assist with the dispute/rebuttal process for diagnosis code discrepancies.

RADV:

• Perform Record Retrieval for internal Mock – RADV, CMS Improper Payment Measurement (IPM) activities, etc.
• Collaborate with Provider Services when needed to assist with record retrieval.
• Review the medical records to identify the one best supportive record for the HCC/diagnosis code targeted by CMS.
• During Mock RADV and IPM audits, collaborate with the Risk Adjustment team for second level review of the record(s) chosen to submit to CMS.
• During Contract RADV audits, collaborate with the Vendor and the Risk Adjustment team to review charts selected for RADV submission.
• Assist/perform the submission of chart notes to CDAT in accordance to CMS’s regulations.

Other Coding Activities:

• Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of coding standards, anatomy, physiology, pathological processes of disease, and medical terminology.
• Follows ICD-10-CM Official Guidelines for Coding and Reporting, AHA Coding Clinics, along with CMS guidance and regulations.
• Accurately and efficiently review medical records to abstract diagnoses for proper ICD-10-CM and/or hierarchical condition category (HCC) code assignment to the highest level of specificity as supported by documentation.
• Maintains confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Serve as subject matter expect on risk adjustment diagnosis coding guidelines.
• Abide by ethical coding standards as set forth by the American Health Information Management Association (AHIMA) and/or the American Academy of Professional Coders (AAPC).
• Other Duties Assigned

EDUCATION AND EXPERIENCE

Education:

• High School Diploma or GED

Required Experience:

• Coding Certification: CPC, RHIT, CCS, or CCS-P
• 1+ year(s) of HCC coding experience.
• 1+ year(s) previous experience with paper and/or electronic medical records required.
• Must have a thorough understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics

Preferred Experience:

• Associates Degree
• CRC along with one of the required certifications
• 4+ year(s) of HCC coding experience.
• Experience with CMS RADV audits.
• Extensive knowledge about the CMS HCC Model

Other Requirements:

• Valid Driver's License

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KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

• Medicare Risk Adjustment (HCC) coder with a strong knowledge of ICD-10-CM diagnostic coding.
• Strong knowledge of base medical terminology, medical abbreviations, pharmacology, and disease processes.
• Familiarity with common EMR applications and proficient in Microsoft Office (Word, PowerPoint, Excel, Outlook)
• Excellent verbal and written communication skills.
• Team-player with self-motivation, problem-solving, and attention to detail.
• Ability to meet productivity and accuracy standards.
• Ability to defend coding decisions to both internal and external audits.

Preferred Competencies:

• Understands the impact of ICD-10 codes on the CMS HCC risk adjustment model.
• Knowledge of RAPS / EDS data types and other Risk Adjustment audits.
• Demonstrated ability to gather and analyze data to identify trends.

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.