Medicare Risk Adjustment Coding Specialist

🕒 4 days ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥 Medical Billing and Coding

🚫👨‍🎓 No degree required

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American Health Partners

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1976

⚕️ Healthcare Insurance

Healthcare Insurance

American Health Partners is a healthcare organization focused on improving access to and coordination of high-quality care through a continuum of services tailored to institutional and special-needs populations. The company operates institutional special needs health plans and provides specialized care coordination, geriatric inpatient and acute psychiatric care, and pharmacy services for long-term-care facilities, supported by an owned/affiliated network of locations and thousands of contracted providers. American Health Partners emphasizes convenient, preventive care to reduce costly hospital stays and improve patient outcomes and quality of life.

📋 Description

• Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes • Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement • Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured • Develop tools and metrics to improve accuracy and completeness of coding and documentation • Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards • Escalate appropriate coding audit issues to management as required • Participate in and support ad-hoc coding audits as needed • Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit • Work assigned coding projects to completion • Other duties as assigned

🎯 Requirements

• Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment • Follow all appropriate Federal and state regulatory requirements and guidelines, as well as company policies and procedures • Maintain established levels of production and quality standards • Knowledgeable of CMS requirements regarding claims processing and coding • Knowledgeable of coding/auditing claims for Medicare and Medicaid plans • Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing • Strong interpersonal skills • Excellent written and verbal communication skills • Strong organizational skills; ability to time manage effectively • Maintain confidentiality • Strong analytical and critical thinking skills required • Ability to work remotely without direct supervision • Successful completion of required training • Handle multiple priorities effectively • Education: High school or equivalent degree • Experience: 2 years’ experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system • 2 years’ experience in managed healthcare environment related to claims and/or coding audits • 2 years’ experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others • 2 years’ experience with CMS requirements regarding claims processing and coding • 2 years’ experience coding/auditing claims for Medicare and Medicaid plans • Significant HCC experience (including knowledge of HCC mapping and hierarchy) • License/Certification: Coding certification required (CPC or CRC)

🏖️ Benefits

• Affordable Medical/Dental/Vision insurance options • Generous paid time-off program and paid holidays for full time staff • TeleDoc 24/7/365 access to doctors • Optional short- and long-term disability plans • Employee Assistance Plan (EAP) • 401K retirement accounts with company match • Employee Referral Bonus Program