Senior Hierarchical Category; HCC) Coding Specialist

JOB SUMMARY

This job will deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding.

Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums.

May also complete analysis on provider coding trends, create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis.

Highmark Inc.

This job will deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding.

Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums.

May also complete analysis on provider coding trends, create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis.

• Conducts data analyses from medical record reviews; proactively summarizes opportunities to enhance provider documentation to improve coding accuracy and thorough capture of members’ chronic health conditions. Conducts quality reviews of high-risk and incremental HCCs and applies expertise to analyze documentation and mitigate risk to the organization. Collaborates with team members to optimize data collection and review, provider education and outreach, and coding quality.
  20%
• Develops and presents process improvement and training initiatives to improve efficiency and accuracy of departmental coding practices. Regularly presents and contributes to coding education meetings and Annual Coding Summit. Adapts presentation style to audience; provides constructive feedback; presents in-person, virtually and/or by webinar.…