Risk Adjustment Coder - Risk Management

Job Details

Physician Office | Kettering | Full-Time | First Shift

This position under the direction of the Manager of Professional Services Coding is responsible for coding compliance, HCC capture and EPIC WQ Reconciliation.

Serves as the subject matter expert ensuring coding compliance, knowledge of CMS billing rules and regulations and serves as a professional fee coding resource to network service lines.

• Demonstrates knowledge of CPT, HCPCS, ICD-10 and CMS NCCI edits
• Reviewing the ambulatory records for the appropriate risk adjustment components
• Identify opportunities for the provider to have supplemental documentation to support the Hierarchical Condition Category (HCC) codes
• Accurately assess documentation in EPIC EMR to assign appropriate CPT, HCPCS and ICD-10
• Reviews and researches pending and denied claims pertaining to professional fee coding, CMS NCCI edits, and/or medical necessity requirements [CMS LDC/NCD and/or payer policy]
• Demonstrate initiative for maintaining current knowledge of CPT, ICD-10 and CMS NCCI edits
• Corresponds with providers on pending claims to facilitate resolution
• Responsible for participating in departmental goals, KHN mission and implemented KHN/KPN policies
• Communicate appropriately with providers, leaders, and staff
• Researches and resolves concerns timely

The Risk Adjustment Coder is responsible for coding and abstracting all outpatient patient records using ICD-10-CM and CPT/HCPCS coding rules, federal guideline and KMCN guidelines. Additionally, the Risk Adjustment Coder supports hospital’s accounts receivable goals through timely processing of records and physician record completion activities. Impacts delivery of quality patient care and enhanced clinical decision-making process. Supports clinical outcomes measurement and assessment process for service lines.

Completes assigned duties and other related tasks. The list is not inclusive, performs other duties as assigned.

The Risk Adjustment Coder will supplement the educational offerings of the MSO by providing right-time feedback to providers when documenting or coding the risk adjustment on patient records. The Risk Adjustment Coder will contribute to overarching educational efforts of the MSO regarding Risk Adjustment. The Risk Adjustment Coder will offer summarized content, feedback from providers, key barriers or success efforts to executive leaders to assist in the overall risk adjustment of the population.

The Risk Adjustment Coder will spend some in-person time with providers to foster a relationship and encourage dialogue with risk adjustment to improve overall outcomes. The Risk Adjustment Coder will develop a collegial relationship with the Clinical Documentation Specialist RN (CDS) to partner on the overarching risk adjustment of the population.

• High School Diploma or equivalent
• RHIT, RHIA, CCS, CCS-P, CPC or eligible specialty certification
• Prior experience in professional fee coding/billing
• CRC required within 1 year of hire