Under the direction of the Risk Adjustment Supervisor/Manager, performs accurate and timely review and validation of Medicare Advantage, Commercial and Medicaid HCCs through medical record reviews. The Risk Adjustment Coding Specialist II reviews provider documentation of ICD-10-CM (including ICD-9-CM) codes to verify that coding meets both established coding standards as well as CMS and ACA Risk Adjustment guidelines. The Coding Specialist II will lead efforts to evaluate the HCC coding practices and provide analyses and recommendations to improve overall provider documentation and coding. The Risk Adjustment Coding Specialist II will review medical records to determine if diagnostic codes (ICD-9/10-CM) are accurately reflecting the provider documentation. The Risk Adjustment Coding Specialist II will summarize findings for internal and external parties. The Coding Specialist II will work on a broad range of audit projects including those with high business impact and that require high levels of expertise and risk adjustment coding experience.

Key Responsibilities/Duties – what you will be doing

• Performs ongoing audit of medical records from coding vendor and network providers to ensure diagnosis coding accuracy.
  • Performs medical record audit to determine coding accuracy to coding standards and CMS regulations.
  • Evaluates medical records for appropriate written and electronic signatures as well as other technical requirements.
  • Collaborates with THP staff and vendors to identify and submit coding adjustments, as needed.
  • Performs HHS-RADV Audits to include preparing chart for Initial Validation Auditor (IVA). Evaluates results from IVA and when applicable, provides ICD-10-CM Guideline(s), AHA Coding Clinic and/or CMS Guidelines to support the validity of the ICD-10-CM code assignment.
  • Maintains a current and strong understanding of coding rules and CMS guidelines in both inpatient and outpatient settings. Priority for the Risk Adjustment Coding Specialist II to compliantly interpret and incorporates ICD-10-CM and ICD-9-CM coding guidelines and CMS regulations. Incorporates changes to guidelines and regulations into audit work in a timely manner.
  • Researches and resolves coding questions and risk adjustment regulatory issues. Coding Program Evaluation.
  • Provides coding expertise to evaluate internal and vendor coding program opportunities.
  • Summarizes and presents recommendations to key internal staff. Reporting. Reviews reports from coding vendors.
  • Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action.
  • Maintains productivity levels as defined by the Manager / Supervisor for a Coding Specialist II by project type and accuracy levels as defined by the Manager / Supervisor for a Coding Specialist II by project type.

Qualifications – what you need to perform the job

• Completion of a formal coding certification program required. Certified Professional Coder (CPC-A, CPC, CPC-H, COC, CIC, or CRC) certification or Certified Coding Specialist (CCS-P or CCS) required.
  • ICD-10-CM coding proficiency and CRC certification required.
  • 5 years of coding experience is preferred. Coding experience in a health plan, hospital or physician practice, billing and/or hospital care management environment required.
  • Prior experience with Risk Adjustment coding and auditing preferred. Thorough knowledge of medical terminology, ICD-9-CM and ICD-10-CM coding and documentation requirements as applicable to Risk Adjustment.
  • Understanding of both the medical and business side of healthcare operations.
  • Ability to read and understand Medicare Advantage and ACA Risk Adjustment protocols.
  • Professional, highly organized, self-motivated, detail-oriented and energetic team player who can also work independently.
  • Ability to multi-task in a fast-paced environment.
  • Strong computer skills including MS Office particularly Excel and Word, Internet, and E-mail, the ability to navigate internal network and external internet data portals required
    Microsoft Access and Excel Intermediate to Advanced level skills preferred.
  • Strong organizational skills and an ability to work autonomously required. Enjoys working in a team environment and participating in the development of departmental quality initiatives.
  • Strong problem solving ability.
  • Good interpersonal skills.
  • Ability to write clearly and succinctly in a variety of communication settings and styles.
  • Ability to effectively communicate with multi-level personnel, medical professionals, clients, public and other representatives of the business.
  • Self starter with ability to learn quickly.
  • Ability to successfully work on multiple projects/accounts simultaneously with frequent interruptions.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8030