HCC Auditor

Job Purpose

Under the direction of the management team, the HCC Auditor is responsible for performing concurrent, prospective and retrospective chart reviews and data validation in effort to improve department’s RAF score goals and maximize HTMG’s revenue. This position is responsible for reviewing and validating electronic based medical charts to ensure the accuracy of the HCC codes captured in the encounter data submission is supported by the provider documentation. The HCC auditor will also perform physician queries for coding and documentation clarification during the prospective chart review process. The incumbent will assist in identifying and assessing coding opportunities, and areas needed for provider educational outreach activity. The incumbent will also support the management team in selecting the best medical records for Health Plan (s) chart review audits and/or CMS RADV audits. This position is reported to the Director of Risk Adjustment/HCC coding.

In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. As a HCC Auditor at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

1. Integrity: Do the right thing, the right way, every time.Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.
2. Compassion: Treat everyone with respect and dignity.Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.
3. Synergy: Collaborate to improve outcomes.Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.
4. Stewardship: Use resources responsibly and efficiently Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Essential Job Duties & Responsibilities

• Conduct both prospective and retrospective chart review audits on outpatient medical chart notes to ensure the accuracy and completeness of documentation that reflects accurate coding selection per ICD-10 CM guidelines/reporting, which substantiates HCC codes captured and submitted to CMS for reimbursement.
• Review medical record information to identify and assess accurate coding based on CMS- HCC categories and abstract HCC data from provider chart notes if not captured or submitted via encounter/claim data submission during CMS sweep periods.
• Assist with the concurrent chart review process and perform physician queries for coding and documentation clarification following physician query policy and procedure standards.
• Maintain a tracking and management tool for assigned medical record review projects.
• Meet and maintain productivity and quality metrics as defined and required by QA policy.
• Participate in Health Plan’s RACCR audits, CMS Risk Adjustment Data Validation (RADV) audits as needed.
• Assist the management team in selecting “best medical records” that validate and support HCC codes.
• When necessary assists the Director of HCC coding with post-chart review audit finding reports.
• Stay abreast with state, federal rules, regulations, and ICD-CM coding guidelines.
• Attend Optum coding/documentation webinars and or other coding source learning opportunity webinars on a monthly basis such as AHIMA, AAPC, etc.
• Follow HIPAA protocol and comply with state and federal regulations.
• Additional duties or project may be assigned by management team as needed.

Experience

• Must possess a minimum of 3 years of coding experience and at least 1 year of HCC/risk adjustment coding experience required with emphasis in the managed care environment or healthcare plan.
• Up to 1 years of auditing experience and extensive knowledge in Medicare HCC coding protocol required.
• Prior work experience in the healthcare field with emphasis on coding and auditing of medical charts is required.
• Ability to work in a fast-paced production environment while maintaining high quality.
• Must be able to follow instructions, meet deadlines given and work independently.
• Ability to identify HCC improvement opportunities and provide feedback to physicians on proper clinical documentation, HCC compliance, and coding guidelines.

Education

• High School diploma; and/or relevant equivalent and relevant work experience required; AA degree or Bachelor's degree in a related field preferred.
• Active Certifications through AHIMA and/or AAPC: Certified Professional Coder (CPC); Certified Coding Specialist (CCS); Physician (CCS-P); Registered Health Information Technician (RHIT); and Certified Risk Adjustment Coder (CRC) preferred.

Knowledge, Skills & Abilities

• Advanced knowledge of ICD-10-CM, CPT, and HCPCS coding, medical terminology, abbreviation, anatomy and physiology, major disease process, and pharmacology.
• Familiar with CMS payment and reimbursement methodology in the managed care environment.
• Knowledge of CMS risk adjustment/HCC model with coding and documentation guidelines.
• Ability to interpret clinical chart documentation, analyze and apply accurately to coding guidelines and reporting followed by the principle of MEAT.
• Must possess strong knowledge of medical chart review audit experience in HCC coding and CMS RADV audits.
• Must possess a high degree of accuracy, efficiency, and dependability.
• Must possess time management, research, strong analytical, organizational, and problem-solving skills.
• Utilize creative thinking, and prioritize assignment projects to ensure deadlines are met.
• Must have strong oral and written communication and presentation skill sets.
• Must be detail-oriented, able to work independently with minimal supervision with highly confidential information per HIPAA regulation.
• Proficiency in Microsoft Outlook, Excel, Excel, and Presentation PowerPoint.