Responsible for overseeing the quality of both outpatient and inpatient coded clinical and administrative date. Responsible for synthesizing audit findings to provide actionable feedback to physicians and administrators on areas of improvement. Candidate is expected to be an active participant in continuous quality improvement processes and workgroups with a strong partnership with HCC co-worker specialists and other quality management staff. Educate providers and administrative staff on correct coding and charting as it applies to Medicare Advantage and Covered CA members. Will provide in-services in small and large group settings. May requires driving to Southern CA clinics and provider offices.
Duties and Responsibilities
- Reviews and audits medical records at provider offices/clinics to identify coding risk areas and ensure that training activities are addressing these areas.
- Review records for completeness, accuracy and compliance with regulations.
- Identify and communicate documentation deficiencies to providers to improve documentation for accurate risk adjustment coding.
- Using independent judgement and sensitivity, review with individual physicians and clinic administrators their audit findings and make suggestions for coding improvements.
- Provide written documentation of potential HCC codes to providers at the point of care while ensuring accuracy of coding and documentation.
- Resolve or clarify codes or diagnoses with conflicting, missing or unclear information by consulting with providers.
- Provide expertise in reviewing and assigning accurate medical diagnoses codes for a wide variety of clinical cases based on services performed by physician and other qualified healthcare providers in the office or clinic setting.
- Demonstrate sound knowledge of medical coding guidelines and regulations to assist providers and clinic administrators the impact of diagnosis coding on risk adjustment payment models.
- Maintain a professional and supportive working relationship with clinic staff, health plan staff, administration and physicians.
- Demonstrate high level of proficiency with documentation review including review of orders/results for lab, imaging, hospital records, EHR, etc. as a possible source for HCC codes.
- Participate in meetings as requested in order to establish and maintain interdepartmental and external partner communication and cooperation.
- Work with offices to coordinate completion of Annual Wellness Visits (AWV) for Medicare and Covered CA members.
- Identifies training needs; prepares training materials and conducts coaching and training as appropriate for clinic staff, physicians and other staff to improve the quality of the diagnosis documentation and accuracy of the collection and coding of members’ health data.
- Performs miscellaneous job-related duties as assigned and requested.
Minimum Job Requirements:
- Bachelor’s Degree or equivalent experience in finance/business, medical records technology, health services administration, nursing or other ancillary medical area.
- Certification in one of the following: Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Coding Specialist (CCS) and three or more years of coding experience. (within physician practice, health plan, IPA or MSO setting preferred)
Knowledge, Skills and Abilities Required:
- Strong written and oral communication skills.
- Proficiency with Microsoft Office Programs; primarily Word and Excel 2013 or higher
- Demonstrated expertise with CPT, ICD-10-CM, medical anatomy and terminology in assigning accurate diagnosis coding
- Sound knowledge of medical coding/billing guidelines and regulations including compliance and reimbursement
- Working knowledge of Medicare risk adjustment principles and audit processes
- Ability to multitask and work under pressure to respond appropriately in all situations
- Ability to establish and maintain effective working relationships with physicians and staff
- Willingness to collaborate with peers to enhance teamwork and performance of all Clinic functions
- Current CA Driver’s license with current auto insurance
- EZ-CAP® knowledge a plus.