Sr Risk Adjustment Coding Specialist

Who we are

About the Role

The Senior Risk Adjustment Coding Specialist is responsible for coordinating, monitoring, and performing documentation and coding audits for risk adjustment. This role supports developing and performing provider education, assists Risk Adjustment Coding Manager with identifying opportunities for process improvement, performs overread and peer review of other coding team member output, and supports determining work assignment distribution.

To be successful in this role, you:

• Are committed to advancing diversity, equity, and inclusion across CHPW.
• Have a minimum of 5 years of experience in medical coding, preferably in a health plan setting.
• Are a Certified Risk Adjusted Coder (CRC).
• Are a certified American Health Information Management (AHIMA) Certified Coding Specialist (CCS), or American Academy of Professional Coder (AAPC) Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H) Coding Certificate.
• Have proficiency in Microsoft Office applications such as Outlook, Word, Excel.

Essential functions and Roles and Responsibilities:

• Support updating and maintaining CHPW coding guidelines to reflect changes of the ICD-10 CM Official Guidelines for Coding and Reporting, new AHA Coding Clinic Advices and new guidance from Center for Medicare & Medicaid Services (CMS). Interpret changes in the external regulatory environment and support modifying CHPW policies accordingly in coordination with Risk Adjustment Coding Manager and Risk Adjustment Program Manager. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Update and distribute provider feedback reports periodically / as needed for identifying provider performance trends, and participate in creating materials. Share all significant audit findings including trends and associated recommendations (e.g., training, oversight, monitoring, process flow changes, documentation, and coding education) specific to internal departments, coding vendors, and others.
• Coordinate with the Risk Adjustment Coding Manager to prioritize tasks of other full time and/or temporary coding staff. Support overread and validation of other coders documentation performance. 
• Lead the risk adjustment coding and documentation quality assurance process, and oversee the workflow of the retrospective coding review
• Present findings via verbal and written updates to internal and external audiences including peer to peer, department leadership (Director, Sr. Director, VPs)_ reporting, provider and clinical teams, and vendor support teams.
• Identify and implement practices and QA process improvement opportunities.
• Monitor and comply with internal coding guidelines, department policies, and CMS risk adjustment guidelines, rules, and regulations. Stay current with changes in the external regulatory environment and modify CHPW policies accordingly. Ensure timely review of regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Support chart audit processes, including audit provider and vendor documentation of ICD-9 and ICD-10 codes to ensure adherence with Center for Medicare Services (CMS) risk adjustment guidelines, and act as a liaison between internal departments and external entities on regulatory data validation audits (including CMS RADV and HHS RADV).
• Perform root cause analysis to identify issues that may contribute to coding and documentation deficiencies.
• Perform internal and external coding quality reviews to validate correct ICD-10-CM code assignments
  • Exempt – Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities

• Knowledge of risk adjustment coding guidelines, regulations, and industry trends and best practices and technology advancements.
• Knowledge of CMS Hierarchical Condition Categories (HCCs) and HHS-HCC models.
• Knowledge of Medicaid Chronic Illness and Disability Payment System (CDPS) model.
• Ability to work with Natural Language Processing (NLP), and computer assisted coding applications.
  
  Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime. Based on market data, this position grade is 65 and has a 10% annual incentive target based on company, department, and individual performance goals.

CHPW offers the following benefits for Full and Part-time employees and their dependents: 

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking, and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion

Mental:

• Frequent decision-making.

*Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

*The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities, or requirements of this position. Job descriptions may be updated or changed to reflect business needs.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.