What are the responsibilities and job description for the Risk Adjustment & Quality Educator position at Altais Health Solutions?
About Your Team
Are you looking to work with a high performing, fast growing and dynamic Risk Adjustment team? Altais and our subsidiaries, form one of the most recognized medical groups in California. We are 4,000 physicians, working in over 40 cities in California, caring for more than 500,000 patients. If working in a mission driven organization supporting highly competent, hard-working, thoughtful clinicians who value good ideas and are passionate about reshaping healthcare excites you, then we are thrilled to welcome you to your new career.
You will focus on:
- Manage multiple projects, including coding updates, revenue cycle management-related reporting and analytics and process improvement initiatives with the medical groups.
- Accountable for reviewing and assigning accurate CPT II and ICD-10 CM Codes for outpatient and inpatient professional services for the Altais provider network
- Ensuring the accuracy of all medical documentation and establishing compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other government regulations
- Performs coding analysis and supports end users and business partner’s needs; identifies and communicates coding risk areas, providing mitigation strategies and recommendations to various stakeholders.
- Accountable for working with the Director of Risk Adjustment & Quality to address improving processes and tools used to document and code clinical services provided by Altais’s providers throughout the enterprise to meet changing business and regulatory conditions.
- Set objectives for documentation and track performance against those objectives with key stakeholders.
- Work in partnership with Operation’s administrators to coordinate the development of education programs relative to coding and documentation improvement.
- Collaborate with Operation’s administrators and providers to review and update orientation and educational materials, documentation tip sheets and training programs/resources.
- Assess Altais’s clinical systems to ensure the accurate and complete capture of clinical information that can be extracted and transmitted to payers, regulators, and other parties.
- Collaborate with Legal & Compliance to review proposed regulatory changes and provide subject matter expertise regarding associated impacts to Altais’s clinical operations.
- Anticipate and effectively address short- and long-term effects of regulatory and industry standard changes to business processes.
- Coordinate with and supports Altais’s leaders in meeting strategic and operational goals concerning documentation, coding, and reporting.
- Develops a regular meeting series to provide consistent coding and documentation feedback and training to clinicians.
- Collaborate and manage risk adjustment reports and work queues across various verticals
- Create process maps and documentation to improve workflows impacting the revenue cycle; evaluate whether process changes improved results; conduct education sessions about new procedures.
- Responsible for researching and providing accurate coding for rejected claims; works and resolves charge edit work queues daily.
- Acts as primary coding resource for medical groups including abstraction of complex surgical reports.
- Must abide by the standards of Ethical Coding and adhere to all official coding guidelines.
- Accountable for reviewing coding of hospital-based services.
- Attends internal coding review team meetings for continued learning and knowledge advancement.
- Utilizes superior customer service to clearly communicate opportunities to improve documentation and coding practices, using knowledge of both government and non-government coding trends and reimbursement rules.
- May be accountable for, or assist in, entering demographic and insurance information into the electronic medical record (Epic) for hospital-based services.
- May support special projects related to reimbursement analysis, new service line development and electronic medical record implementation
- Northern and Southern California 80% travel to local provider(s) offices and provider network for Altais
Additional Requirements
- Access to a reliable, insured vehicle is required, with mileage reimbursement provided
- Valid driver’s license
- Ability to pass a background check and motor vehicle record (MVR) check
- Associate degree or 3 years of relevant experience
- 5 years of related professional Risk Adjustment & Quality education experience required.
- 2 years of experience with ICD-10 CM
- Experience providing training and education to staff and clinicians using excellent verbal and written communication skills, effective technical skills, have positive demeanor and exhibit professionalism in approach
- Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC) required
- Awareness of Quality measures and the importance of quality gap closure.
- Must demonstrate expertise in medical coding guidelines and regulations, including compliance and reimbursement rules.
- A strong understanding of physiology, anatomy and medical terminology.
- Expertise in denials management identifying root causes and proposing solutions.
- Ability to maintain a high level of integrity and confidentiality of medical information.
- Organization skills
- Strict attention to details
- Detail oriented with excellent written and verbal communication
- Unparalleled multi-tasking abilities
- Critical thinking skills
- Ability to react to resets and changes in a fast-paced environment
- Able to learn and work with a variety of different tools and applications required for the role
- Experienced educator with a strong understanding of the requirements for clinical coding and CPT II billing according to the rules of Medicare, Medicaid, and commercial payers
- Electronic medical record and chart review experience
- You are passionate about improving the healthcare experience and want to be part of the Altais mission.
- You are bold and curious- willing to take risks, try new things and be creative.
- You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
- You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
- You co-create, knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.
- You build trust with your colleagues and customers by demonstrating that you are someone who values honesty and transparency.
Altais values the contribution each Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience within the job or the industry. The pay scale listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this job description. Additional pay may be determined for those candidates that exceed these specified qualifications and requirements. We provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.
The anticipated pay range for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, and experience.
Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of workday.
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Job Summary: The Risk Adjustment & Quality Educator is part of the Altais Risk Adjustment & Quality team and provides coding support for Altais’s clinicians. The Educator measures accuracy and general completeness of medical record documentation to assess the appropriateness of code assignments, such as ICD-10-CM and CPT II codes with Federal and State requirements for professional fee billing and medical record documentation.
Essential Functions:
- Manage multiple projects, including coding updates, revenue cycle management-related reporting and analytics and process improvement initiatives with the medical groups.
- Accountable for reviewing and assigning accurate CPT II and ICD-10 CM Codes for outpatient and inpatient professional services for the Altais provider network
- Ensuring the accuracy of all medical documentation and establishing compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other government regulations
- Performs coding analysis and supports end users and business partner’s needs; identifies and communicates coding risk areas, providing mitigation strategies and recommendations to various stakeholders.
- Accountable for working with the Director of Risk Adjustment & Quality to address improving processes and tools used to document and code clinical services provided by Altais’s providers throughout the enterprise to meet changing business and regulatory conditions.
- Set objectives for documentation and track performance against those objectives with key stakeholders.
- Work in partnership with Operation’s administrators to coordinate the development of education programs relative to coding and documentation improvement.
- Collaborate with Operation’s administrators and providers to review and update orientation and educational materials, documentation tip sheets and training programs/resources.
- Assess Altais’s clinical systems to ensure the accurate and complete capture of clinical information that can be extracted and transmitted to payers, regulators, and other parties.
- Collaborate with Legal & Compliance to review proposed regulatory changes and provide subject matter expertise regarding associated impacts to Altais’s clinical operations.
- Anticipate and effectively address short- and long-term effects of regulatory and industry standard changes to business processes.
- Coordinate with and supports Altais’s leaders in meeting strategic and operational goals concerning documentation, coding, and reporting.
- Develops a regular meeting series to provide consistent coding and documentation feedback and training to clinicians.
- Collaborate and manage risk adjustment reports and work queues across various verticals
- Create process maps and documentation to improve workflows impacting the revenue cycle; evaluate whether process changes improved results; conduct education sessions about new procedures.
- Responsible for researching and providing accurate coding for rejected claims; works and resolves charge edit work queues daily.
- Acts as primary coding resource for medical groups including abstraction of complex surgical reports.
- Must abide by the standards of Ethical Coding and adhere to all official coding guidelines.
- Accountable for reviewing coding of hospital-based services.
- Attends internal coding review team meetings for continued learning and knowledge advancement.
- Utilizes superior customer service to clearly communicate opportunities to improve documentation and coding practices, using knowledge of both government and non-government coding trends and reimbursement rules.
- May be accountable for, or assist in, entering demographic and insurance information into the electronic medical record (Epic) for hospital-based services.
- May support special projects related to reimbursement analysis, new service line development and electronic medical record implementation
- Northern and Southern California 80% travel to local provider(s) offices and provider network for Altais
