Excellus BCBS
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Risk Adjustment Coding Coordinator I/II
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Excellus BCBS Overview
The Risk Adjustment Coding Coordinator is responsible for decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position handles risk adjustment coding and quality assurance validation for programs including but not limited to prospective and retrospective medical record reviews, Sole Source and Potentially Unvalidated Diagnoses (PUD) reviews, and RADV-related activities. Responsibilities
Prospective medical record review of health plan providers. Retrospective medical record review of health plan providers. Sole Source and Potentially Unvalidated Diagnosis (PUD) reviews. Risk Adjustment Data Validation (RADV) Audits. Essential Accountabilities
Level I
Reviews medical records to determine if specific disease conditions were correctly reimbursed and documented. Reports findings of the data validation review and submits adjustments as needed to the appropriate processing/adjustment area (Risk Adjustment/Actuarial Services). Performs vendor QA and sole source PUD coding projects, including oversight of read/over-read assignments. Supports vendor discussions and feedback related to quality audit findings. Presents results and learning opportunities to the team. Serves as a coordinator and key business resource for the Risk Adjustment Coding Coordination Team. Conducts reviews and audits using knowledge of ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial HCC coding, and Medicaid CRGs to ensure compliance. Assists in developing, implementing, evaluating and updating desktop processes, policies and procedures and business rule tools governing responses to RADV audits, prospective and retrospective medical record coding. Works with vendors, providers and hospital Medical Records Departments and Business Office staff to coordinate medical record access and reviews in a timely fashion. Meets or exceeds productivity targets and due dates as assigned. Ensures project activities follow applicable coding guidelines, NYS law, and federal regulations. Provides peer-to-peer guidance through informal discussion and over-read assignments. Supports coder training and orientation as requested by leadership. Maintains accuracy in coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences to maintain AHIMA and/or AAPC certifications. Shares information from professional activities with management and staff as applicable. Keeps management apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success. Upholds Lifetime Healthcare Companies’ mission and values, adheres to the Corporate Code of Conduct, and supports the Lifetime Way values and beliefs. Maintains member privacy in accordance with corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in Addition To Level I Essential Accountabilities)
Serves as a liaison between the Plan, provider offices/hospitals, and vendor representatives for prospective and/or retrospective coding and QA validation reviews, including obtaining medical records and verifying data elements. Trains, mentors and supports new employees during orientation; acts as a resource for existing staff on projects and daily work. Researches best practices in risk adjustment coding and reviews professional literature for coding updates; maintains currency in coding. Evaluates and recommends enhancements to the risk adjustment program. Proposes and develops new desk-level procedures (DLPs) and policies and procedures (P&Ps) to support department initiatives, audits, and projects; reviews and updates existing DLPs, workflows, and P&Ps for accuracy. Establishes and maintains a repository for storing department documentation (e.g., corporate share drives, wiki, intranet). Provides recommendations to management related to process improvements, root-cause analysis, and barrier resolution for Risk Adjustment initiatives. May assist or lead projects and/or handle higher work volume than Risk Adjustment Coding Coordinator I. Minimum Qualifications
All Levels Current Coding Certification (CPC, CPC-H, CPC-I, CCS) through AHIMA or AAPC required, with a minimum of one (1) year coding experience or directly related medical experience. In lieu of certification and coding experience, CPC-A or CCA certification is required. High school diploma required. Knowledge of medical terminology and disease processes. Knowledge of medical coding methodologies, conventions and guidelines (e.g., ICD-9-CM, ICD-10, CPT, HCPC). Familiarity with CMS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements preferred. Strong written and verbal communication skills; strong analytical, organizational, and time management skills. Able to work independently and within time constraints. Recognizes and properly handles confidential health information. Able to efficiently prioritize multiple high-priority tasks. Previous auditing experience desirable. Level II (in Addition To Level I Minimum Qualifications)
Minimum of two (2) years coding experience or directly related medical experience, including one year in HCC coding. Advanced knowledge of medical terminology, anatomy and physiology, major disease processes, and pharmacology. Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing, and health care reimbursement systems. Comprehensive understanding of ICD-9, ICD-10, and other coding used by contracted facilities and providers. Ability to utilize a variety of electronic medical records systems. Ability to manage significant workload and meet deadlines with minimal supervision; strong time management, accuracy, and dependability. Strong communication skills across organizational levels; strong analytical and mathematical skills. Experience in project completion, educational program development and/or group presentation. Knowledge of the healthcare industry. Physical Requirements
Prolonged periods of sitting/standing at a workstation and working on a computer. Prolonged use of keyboard, mouse, and phone for three hours or more. Ability to work in a home office for extended periods for business continuity. Ability to travel across the Health Plan service region for meetings/trainings as needed. Manual dexterity and repetitive motion required; reaching, crouching, stooping, kneeling as needed. Equal Opportunity Employer One Mission. One Vision. One I.D.E.A. One you. We’re committed to inclusion, diversity, equity, and access; we encourage all qualified individuals to apply. Compensation Range(s)
Level I: Minimum $60,410 - Maximum $84,000 Level II: Minimum $60,410 - Maximum $96,081 The posted salary range is the minimum and maximum for this position. Actual salary will vary based on factors including experience, knowledge, skills, and education as they relate to the minimum qualifications, internal equity, and other components of the total rewards package. Remote work opportunities may be available on a case-by-case basis. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Job function: Other; Industries: Insurance
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Risk Adjustment Coding Coordinator I/II
role at
Excellus BCBS Overview
The Risk Adjustment Coding Coordinator is responsible for decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position handles risk adjustment coding and quality assurance validation for programs including but not limited to prospective and retrospective medical record reviews, Sole Source and Potentially Unvalidated Diagnoses (PUD) reviews, and RADV-related activities. Responsibilities
Prospective medical record review of health plan providers. Retrospective medical record review of health plan providers. Sole Source and Potentially Unvalidated Diagnosis (PUD) reviews. Risk Adjustment Data Validation (RADV) Audits. Essential Accountabilities
Level I
Reviews medical records to determine if specific disease conditions were correctly reimbursed and documented. Reports findings of the data validation review and submits adjustments as needed to the appropriate processing/adjustment area (Risk Adjustment/Actuarial Services). Performs vendor QA and sole source PUD coding projects, including oversight of read/over-read assignments. Supports vendor discussions and feedback related to quality audit findings. Presents results and learning opportunities to the team. Serves as a coordinator and key business resource for the Risk Adjustment Coding Coordination Team. Conducts reviews and audits using knowledge of ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial HCC coding, and Medicaid CRGs to ensure compliance. Assists in developing, implementing, evaluating and updating desktop processes, policies and procedures and business rule tools governing responses to RADV audits, prospective and retrospective medical record coding. Works with vendors, providers and hospital Medical Records Departments and Business Office staff to coordinate medical record access and reviews in a timely fashion. Meets or exceeds productivity targets and due dates as assigned. Ensures project activities follow applicable coding guidelines, NYS law, and federal regulations. Provides peer-to-peer guidance through informal discussion and over-read assignments. Supports coder training and orientation as requested by leadership. Maintains accuracy in coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences to maintain AHIMA and/or AAPC certifications. Shares information from professional activities with management and staff as applicable. Keeps management apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success. Upholds Lifetime Healthcare Companies’ mission and values, adheres to the Corporate Code of Conduct, and supports the Lifetime Way values and beliefs. Maintains member privacy in accordance with corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in Addition To Level I Essential Accountabilities)
Serves as a liaison between the Plan, provider offices/hospitals, and vendor representatives for prospective and/or retrospective coding and QA validation reviews, including obtaining medical records and verifying data elements. Trains, mentors and supports new employees during orientation; acts as a resource for existing staff on projects and daily work. Researches best practices in risk adjustment coding and reviews professional literature for coding updates; maintains currency in coding. Evaluates and recommends enhancements to the risk adjustment program. Proposes and develops new desk-level procedures (DLPs) and policies and procedures (P&Ps) to support department initiatives, audits, and projects; reviews and updates existing DLPs, workflows, and P&Ps for accuracy. Establishes and maintains a repository for storing department documentation (e.g., corporate share drives, wiki, intranet). Provides recommendations to management related to process improvements, root-cause analysis, and barrier resolution for Risk Adjustment initiatives. May assist or lead projects and/or handle higher work volume than Risk Adjustment Coding Coordinator I. Minimum Qualifications
All Levels Current Coding Certification (CPC, CPC-H, CPC-I, CCS) through AHIMA or AAPC required, with a minimum of one (1) year coding experience or directly related medical experience. In lieu of certification and coding experience, CPC-A or CCA certification is required. High school diploma required. Knowledge of medical terminology and disease processes. Knowledge of medical coding methodologies, conventions and guidelines (e.g., ICD-9-CM, ICD-10, CPT, HCPC). Familiarity with CMS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements preferred. Strong written and verbal communication skills; strong analytical, organizational, and time management skills. Able to work independently and within time constraints. Recognizes and properly handles confidential health information. Able to efficiently prioritize multiple high-priority tasks. Previous auditing experience desirable. Level II (in Addition To Level I Minimum Qualifications)
Minimum of two (2) years coding experience or directly related medical experience, including one year in HCC coding. Advanced knowledge of medical terminology, anatomy and physiology, major disease processes, and pharmacology. Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing, and health care reimbursement systems. Comprehensive understanding of ICD-9, ICD-10, and other coding used by contracted facilities and providers. Ability to utilize a variety of electronic medical records systems. Ability to manage significant workload and meet deadlines with minimal supervision; strong time management, accuracy, and dependability. Strong communication skills across organizational levels; strong analytical and mathematical skills. Experience in project completion, educational program development and/or group presentation. Knowledge of the healthcare industry. Physical Requirements
Prolonged periods of sitting/standing at a workstation and working on a computer. Prolonged use of keyboard, mouse, and phone for three hours or more. Ability to work in a home office for extended periods for business continuity. Ability to travel across the Health Plan service region for meetings/trainings as needed. Manual dexterity and repetitive motion required; reaching, crouching, stooping, kneeling as needed. Equal Opportunity Employer One Mission. One Vision. One I.D.E.A. One you. We’re committed to inclusion, diversity, equity, and access; we encourage all qualified individuals to apply. Compensation Range(s)
Level I: Minimum $60,410 - Maximum $84,000 Level II: Minimum $60,410 - Maximum $96,081 The posted salary range is the minimum and maximum for this position. Actual salary will vary based on factors including experience, knowledge, skills, and education as they relate to the minimum qualifications, internal equity, and other components of the total rewards package. Remote work opportunities may be available on a case-by-case basis. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Job function: Other; Industries: Insurance
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