HCC Auditor **DOE Hybrid

HCC Auditor

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.

• Integrity
  :
  Do the right thing, the right way, every time.
• Honesty
  :
  Uphold commitments, earn trust and respect, maintain privacy.
• Compassion
  :
  Treat everyone with respect and dignity.
• Inclusivity
  :
  Foster a supportive environment, practice empathy.
• Synergy
  :
  Collaborate to improve outcomes.
• Innovation
  :
  Explore opportunities, promote communication and teamwork.
• Stewardship
  :
  Use resources responsibly and efficiently.
• Implement effective strategies to attain goals, achieve maximum productivity, seek continuous knowledge and improvement.

• 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 assist 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.

• Must possess a minimum of 3 years of coding experience and at least 1 year of HCC/risk adjustment coding experience, 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, work independently.
• Ability to identify HCC improvement opportunities and provide feedback to physicians on proper clinical documentation, HCC compliance, and coding guidelines.

• 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.

• 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,…