Risk Adjustment Coder

Quality Improvement Oakland, California

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Description

The Position:  Responsible for the accurate coding, coding review, and submission of eligible participant diagnoses to CMS.

 Compensation range for the Risk Adjustment Coder role at CEI is $ 59.127 - $ 88,691.   Offers based on level of experience/education as it applies to the requirements for the position

Please note: After 90 days of service, this position will be eligible for a hybrid schedule, 2 days remote per week.

 

DUTIES AND RESPONSIBILITIES:

  • Oversee all aspects of HCC and frailty coding operations for Center for Elders’ Independence.
  • Interprets, analyzes, and assigns diagnostic codes to ensure compliance with governmental reimbursement policies, regulations and applicable guidelines.
  • Reviews provider coded encounters for accuracy of diagnoses.
  • Abstracts all CMS participant eligible diagnoses into a CMS submittal format.
  • Reviews and analyzes medical documentation to ensure that the final diagnosis listed accurately reflects the care and treatment submitted for reimbursement.
  • Collaborates and coordinates with external auditors; provides feedback on audit reports as appropriate.
  • Identifies inconsistencies, discrepancies and/or trends within the medical record and discusses with the appropriate medical providers.  Recommends appropriate modifications.
  • Assigns a variety of diagnostic codes in ICD 10 CM with careful attention to the PACE HCC reimbursement model.
  • Researches, analyzes, and responds to inquiries regarding compliance, coding, and financial impact of coded diagnoses,
  • Maintains record confidentiality in accordance with HIPAA and related rules, policies and procedures. 
  • Coordinates and manages coding reviews from outside vendors.
  • Analysis of diagnostic results for error corrections and trends from CMS submittal reports.
  • Performs related duties as assigned.

 

 

REQUIREMENTS:

  • Associate Degree in Health Information Technology or Bachelor’s Degree in Health Information Administration and two years of medical coding experience; or four years as a medical coder.  Coding experience with a HCC Model is strongly preferred.  
  • Registered Health Information Technician or Administrator (RHIT/RHIA) or one of the following Coding Certifications
    1. Certified Professional Coder
    2. Certified Professional Coder –Hospital Outpatient
    3. Certified Coding Specialist
    4. Certified Coding Specialist –Physician Based
    5. Other AHIMA or CPC certification specific to HCC/Risk Adjustment Coding
  • Must maintain current coding credential.

  

 

KNOWLEDGE OF:

  • Medical terminology, abbreviations, medications, and medical techniques and procedures.
  • Anatomy and physiology; major disease processes and pharmacology.
  • Extensive knowledge of official coding conventions and rules for ICD 10 CM.
  • Extensive knowledge of HCC PACE model or MA HCC model and strong knowledge of PACE or MA Risk Adjusted Payment process preferred.
  • Familiarity with claims process with respect to Hospital, Surgical, and Consultant claims.
  • Medico-legal aspects of health information management including regulations and requirements regarding responsibilities for maintaining patient confidentiality.
  • Writing skills sufficient to prepare reports and other materials.

 

ABILITY TO: 

  • Read and understand complex medical record information and clarify diagnoses/procedures and sequencing of diagnoses as required.
  • Clearly communicate medical coding related information to practitioners and others involved in the care, treatment, billing or reimbursement process.
  • Analyze and resolve complex medical coding issues and make consistently accurate coding decisions.
  • Abstract participant diagnoses and develop abstraction systems/procedures as required.
  • Ability to extract EHR and Claims information into a Coding Database using a semi-automated procedure.
  • Ability to identify and draft Coding User Requirements to the IT department. Ability to track and coordinate Coding Software modifications with the IT department.
  • Code from an EHR. Experience with eClinicalWorks (eCW) preferred.

 

The above job description is intended to communicate the general function of the mentioned position and by no means shall be considered an exhaustive or complete outline of the specific tasks and functions that will be required.  CEI reserves the right to change job descriptions, site assignments, and or work hours as required by the needs of the program.  All employees are expected to perform their duties within their ability as required by the job and/or as requested by management. 

 

 

Center for Elders’ Independence is a PACE (Program of All- Inclusive Care for the Elderly) organization that uses an interdisciplinary team approach to care planning and care implementation for the purpose of providing high quality, affordable, integrated health care services to the elderly, including an Adult Day Health Center, and promoting autonomy, quality of life and the ability of individuals to live in their communities. Unlike other healthcare plans, CEI is not a "fee-for-service" plan. It is a “capitation” healthcare plan. CEI is paid a set amount for each person enrolled in our program, whether or not that individual seeks care. We are a growing company that offers stability and continues to thrive.

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