HCC Coding Risk Adjustment Nurse

Req#: R25143
Category(s): Nursing, Nurse Other
Full Time / Part Time: Full-Time
Shift: First

HCC Coding Nurse

B200

SUMMARY DESCRIPTION

One to three paragraphs describing job function.  In addition to job qualifications this will be used for posting.  This section should include tie to line of sight and employee engagement – how this job relates to our vision and mission.  (Do not use bulleted text.)

The HCC Nurse is responsible for the chart review and ICD-10 diagnosis coding of risk adjustment eligible members. This position will have responsibility for review of medical records to identify appropriate ICD-10 diagnosis codes to capture the complexity of patient conditions and improve the accuracy of the problem list, and increase revenue and avoid losses.  By capturing quality indicators (Healthcare Effectiveness Data and Information Set – HEDIS) and Medicare Risk Adjustments (MRA) the HCC nurse will improve accuracy and completeness of problem lists to reflect chronic conditions per Centers of Medicare and Medicaid Services (CMS) Hierarchical Conditions Categories (HCC) guidelines. .This will support the accuracy of documentation and billing diagnoses and increase physician satisfaction with support provided 

Adheres to system and department compliance policies, and any and all applicable laws and regulations. Performs other duties as assigned.

JOB REQUIREMENTS

Job Requirements:

Expansion of the summary description.  Specific job related responsibilities that will be used to measure performance.  Please check which job responsibilities are “Essential Functions” as defined by the Americans With Disability Act. View ADA Requirements

1)  Reviews documentation and abstracts all codes with specific emphasis on identifying the most accurate severity of illness according to CMS HCC (Hierarchical Conditions Categories) guidelines.Websites(s)- Maintain the Benefits and Disability website as an administrator and perform monthly quality review for hyperlinks and up to date content on the Baystate Healthy website.

2) Effectively uses computer to review and interpret medical records and applies in-depth knowledge of coding principles to validate missing, incomplete or incorrect International Classification of Disease-10 (ICD-10) diagnosis codes.

3) Assist in the development of appropriate forms for data collection and analysis.

4) Applies HCC concepts and determines impact on Population Health Risk Adjustment reimbursement initiatives

5) Acts as primary resource in HCC guidelines and coding practices. Teaches and mentors providers and staff.

6) Utilizes multiple reports related to risk adjustment to determine focus audit or educational outreach and initiatives directly affecting reimbursement.

  a.  Identify and confirm unreported and/or unresolved medical conditions of members based   on supportive medical documentation.

  b.  Applies ICD-10 Diagnosis Codes to Cerner Problem List.

  c. Removes duplicate, non-specific or resolved ICD-10 Diagnosis codes from problem List.

7) Inquires with Physicians when ICD-10 code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes; follows up with Physician until resolved.

8) Inquires with Physicians when ICD-10 code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes; follows up with Physician until resolved.

9) Identifies and reports issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding guidelines.

10) Promotes Medicare Wellness Visits for eligible patients to enhance patient care and improved coding and budget opportunities.     

11) Supports clinical outcome management

12) Supports activities and projects as assigned     

13) Supports onboarding of new patients to assure complete documentation of problem list and health maintenance.

QUALIFICATIONS

Unless otherwise required by certification, licensure, or registration, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the minimally required education and/or experience listed in the Qualifications section below.

Minimally Required Education

Diploma RN

Minimally Required Experience

Three or more years of RN clinical experience

PREFERRED EXPERIENCE

Bachelor's degree

SKILLS/COMPETENCIES

Strong clinical knowledge related to chronic illness diagnoses.

Excellent understanding of clinical documentation requirements in order to support an active diagnosis.

Knowledge of medical terminology, anatomy & physiology, and medical prescription & over-the-counter drugs used to treat conditions.

Skill in communicating effectively both verbally and in writing.

Computer literate in Microsoft Office Suite and coding application used in a functional area.

Detailed oriented.

Skill in planning, organizing, prioritizing and working independently.

Demonstrated skills to meet and exceed productivity and quality expectations.

Knowledge of CMS HCC guidelines and application relevant to improved documentation and favorable reimbursement.

Skill in assessing and taking appropriate action with little guidance.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Assoc of Science in Nursing (Required), Bachelor of Nursing Degree

Certifications:

Driver License – Other, Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

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