Specialist - Medical Billing & Coding

Highmark Inc.

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), using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits.

Works closely with physicians, team members, Quality, Compliance, partners at Enterprise and leadership to identify and deliver high quality and accurate risk adjustment coding. Supports all Remote Patient Monitoring (RPM) risk adjustment projects to comply with all CMS requirements by analyzing physician documentation and interpreting into ICD
10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of correct Risk Adjustment coding including documentation improvement, provider education, analyzing reports, and identifying process improvements.

Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures to guide HCC coding decision making.

Maintains RPM coding accuracy and productivity requirements.

Assists with Regulatory Audits by performing first coding review and ranking of charts. Build partnerships and work within coding teams and internal partners critical to HCC coding.

Participates on ad-hoc projects per the direction of Leadership to address the needs of the department. Provides recommendations for process improvements and efficiencies.

Engages in RPM Coding educational meetings and annual coding Summit.

Other duties as assigned.

Required None

Substitutions None

Preferred Associate degree in medical billing/coding, health insurance, healthcare or related field preferred.

Required3 years HCC coding and/or coding and billing

Preferred5 years HCC coding and/or coding and billing

Required

(any of the following)
Certified Professional Coder (CPC)

Certified Risk Coder (CRC)

Certified Coding Specialist (CCS)

Registered Health Information Technician (RHIT)

Preferred None

Critical Thinking Attention to Detail Written and Oral Presentation Skills Written Communications Communication SkillsHCC CodingMS Word, Excel, Outlook, Power Point Microsoft  Office Suite Proficient/ - MS365 & Teams Language (Other than English):

None Travel Requirement:0% - 25%

Position Type Remote Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)
Never Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer:

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

:

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities,…