HCC Coding Quality Auditor / Educator

Description

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

The HCC Coding Quality Auditor/Educator will facilitate the development and maintenance of HCC coding and audit programs. The programs are designed to accomplish accurate risk adjustment reporting through the complete and accurate assignment of ICD-9-CM and ICD-10-CM codes corresponding to conditions that are considered part of CMS HCC model and are supported in member's medical record.

The HCC Coding Quality Auditor/Educator will be responsible for reviewing provider documentation to verify that all MA risk adjustment documentation requirements are met and will deliver education to providers. The reviewed RA information for compliance and educational objectives must be in strict adherence to Official ICD-9-CM and ICD-10-CM Guidelines for Coding and Reporting, AHA Coding Clinic, CMS, and other organizational policies and procedures.

The profile of the members in the HCC programs could vary from complex and high-risk patients to healthy members with Triple Aim target, which is a) enhance member experience, b) reduce costs, and c) improve health outcomes.

Functions & Job Responsibilities

• Subject matter expert for accurate and appropriate risk adjustment coding and CMS data validation.
• Create compliance policies and review patient records in accordance with compliance policies and coding guidelines.
• Develop programs and training materials for coding compliance monitoring and clinical documentation improvement (CDI).
• Develop and utilize risk-based audit approach to establish scope of reviews by incorporating patterns and trending analysis. Alert the Manager and/or Director of any areas of identified concern.
• Develop workflows to perform quality assurance (QA) auditing.
• Organize/participate in coding reviews/audits of medical records for RA reporting of all supported HCC conditions for submission to CMS.
• Oversee compliance from the coders, vendors, and providers. Prep and share feedback with the entities in a timely manner.
• Identify patterns and trends for educational opportunities.
• Responsible for planning, scheduling, and conducting coding audits; and maintaining records of provider or vendor audit results for HCC diagnosis codes.
• Document audit results and must be able to present audit findings to the HCC Program team, providers, vendors, and other internal departments in an organized and actionable format.
• Comfortable with educating and training peers and providers on a one-to-one or group basis to ensure accurate payment and improve quality of care. The trainings could be in provider offices, hospitals, via webinars/conference calls/email correspondence, etc.
• Positively influence the behavior of others and inspire them.
• Create and maintain positive relationships with peers, leadership, IPA/MSOs, affiliate providers, office managers and all other associates internal or external to the organization.
• Maintain up-to-date knowledge and coding credentials, current updates to governmental requirements and plan requirements related to proper coding through continued education, research and reading resource material.
• Other duties as assigned.

Qualifications

Qualifications

Education and Experience:

• Bachelor’s degree with relevant coursework or 5 years HCC coding/auditing and diagnostic coding and education experience preferred
• Experience in a health plan setting preferred
• Experience in education/training HCC risk adjustment coding and documentation.
• Experience in correct application of M.E.A.T. concepts.
• Current Coding Certification in one or more of the following: CPC, CPC-H, CPC-P, CCS, CCS-P, CCA.
• Valid driver’s license, reliable transportation, and insurance required with clean driving record

Skills:

• Strong knowledge of coding concepts and ability to identify supported/unsupported conditions with a high degree of accuracy.
• Thorough knowledge of advanced ICD-9-CM and ICD-10-CM coding rules and correct application in the context of HCC coding.
• Competent knowledge of Coding Clinic and CMS guidance as they relate to HCC coding.
• Ability to synthesize complex and diverse information in provider documentation.
• Must have strong attention to detail in both coding and all other job-related functions.
• Ability to listen attentively and communicate clearly and concisely.
• Demonstrates strong written communication skills.
• Ability to prioritize and plan work activities effectively.
• Must have a genuine interest in improving and promoting quality.
• Always aspires to meet productivity standards and help improve them.
• Must maintain highest confidentiality of medical record information.
• Ability to interrelate to physicians’ documentation clarification and coding concerns.
• Proficient typing skills and strong computer skills, including MS Office.
• Able to work independently and in a team-based setting.

Wage Range: $70,000/year - $80,000/year

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

Salary : $70,000 - $80,000