Job Description & How to Apply Below
Under minimal supervision, ensures accurate & appropriate documentation through chart reviews as well as provider education and monitoring for both Medicare and Medicaid projects. Provides documentation coaching and feedback to clinicians and coders in the outpatient; inpatient and homebound setting. Monitors and tracks success of training and clinician feedback through encounter reviews which ensure documentation meets requirements for diagnosis assignment, based on official ICD guidelines.
Abstract pertinent information from assigned medical records using ICD-10-CM, CPT and/or HCPCS codes. Provide detailed comments/feedback on physician performance based on encounter reviews. Document detailed chart review findings including all documentation errors; medical record errors; diagnosis errors as well as missed HCC opportunities. Track provider performance and identify documentation training opportunities. Encounter reviews will be the primary monitoring tool used to identify operational and regulatory issues related to coding, documentation, and compliance requirements and to ensure complete and accurate data capture in compliance with Federal and State requirements. Monitor corrective actions of review findings. Serves as a local resource in meeting internal and external regulatory requirements (e.g., Centers for Medicare & Medicaid Service (CMS), National Committee for Quality Assurance (NCQA)). Actively participate with local CMS (Center for Medicare/Medical Services) team to ensure local objectives are met and regional CMS compliance activities are supported. Works with medical center leadership to provide confidential reviews and feedback on an "as needed" basis. Assist in the identification of operational processes that hinder encounter data capture. Prepare and/or perform reviewing analysis and/or special projects as assigned. Provide feedback on noncompliance issues detected through reviewing. Provide review support to the HCC Risk Adjustment program specifically the yearly Wellness Visit Program. Submit weekly and monthly productivity reports. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements.
Partner with Network Management, Provider relations/Provider education departments as well as other analytical workgroups to identify review trends and risk areas based on review findings and data analysis. Assist in developing and implementing policies and procedures / Compliance Review Standards to ensure compliance with Federal, State and other regulatory requirements. Research and provide courteous, accurate and timely response to inquiries from physicians relating to CDPS and CMS Risk Adjustment projects and reports. Provide education and training to health care providers included in the Wellness Program. Serve as resource for internal and external customers to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines and regulatory requirements. Provide one on one physician training and review sessions as deemed necessary. Attendance of additional physician training sessions based on departmental needs. Develop, manage and administer training modules based on CDPS methodology and guidelines for provider and coding staff and leadership.
The qualified candidate must possess 3-5 years of experience in Medicaid related coding. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
A High School Diploma or Equivalent; BS/BA preferred
Must possess and maintain an AAPC or AHIMA certification – CPC, CRC, CDEO, CPMA (or AHIMA equivalent)
3 – 5 years’ experience in healthcare setting related to CDPS/HHS and CMS Risk Adjustment chart review
Working knowledge of CDPS and CMS Risk Adjustment methodology
Demonstrate ability to interact effectively with physicians and their staff
Outstanding communication skills with the ability to persuasively and effectively communicate with internal and external customers in both written and oral form
Ability to make decisions in the absence of detailed instructions
Ability to effectively utilize review tools and software
Ability to create and update an Excel spreadsheet for purposes of tracking and reporting.
Must be proficient in Microsoft Office with the ability to navigate Word, Excel and PowerPoint.
Ability to adapt to constantly shifting priorities in managing a wide-range of projects while remaining a team-player
Demonstrate time management, leadership and interpersonal skills
Be able to work both independently and in a team environment with minimal supervision.
Maintain a positive attitude with changing conditions
Minimum typing speed of forty-five (45) words per minute
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