Excellus BCBS
Risk Adjustment Coding Coordinator I/II – Excellus BCBS
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Risk Adjustment Coding Coordinator I/II
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Excellus BCBS . 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 medical record review of health plan providers Retrospective medical record review of health plan providers Sole Source and Potentially Unvalidated Diagnosis (PUD) reviews Summary / 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. Prepares and submits adjustments to the appropriate processing / adjustment area (Risk Adjustment/Actuarial Services). Performs vendor QA and sole source PUD coding projects, including over-read assignments. May support 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 utilizing knowledge and experience of ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial Hierarchical Condition Category (HCC) coding, and Medicaid Clinical Risk Groups (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 medical record coding, 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 as established by management. Regularly meets 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 all coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences as required by AHIMA and/or AAPC to maintain professional certification. Presents information from professional activities to 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. Demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and aligning with the Lifetime Way values and beliefs. Maintains high regard for 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) Acts as a liaison between the Plan and designated provider/hospital representatives and vendor(s) for prospective and/or retrospective coding and QA validation reviews, including requesting and retrieving medical records, data element verification, ICD-9/ICD-10 coding validation, monitoring plan specifications, HCC assignment accuracy, and RADV audits. Trains, mentors and supports new employees during the orientation process; serves as a resource to existing staff for projects and daily work. Researches best practices in risk adjustment coding and reviews the professional literature for coding updates; maintains currency in coding. Evaluates, researches, and recommends enhancements to the risk adjustment program. Proposes and develops new desk-level procedures (DLPs) and policies/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 required certification and coding experience, CPC-A or CCA certification 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, organization and time management skills. Able to work independently and within time constraints. Ability to handle confidential health information appropriately. Able to prioritize multiple high-priority tasks. Previous auditing experience desirable. Level II
Minimum Qualifications (in addition to Level I) Minimum of two (2) years coding experience or directly related medical experience, including at least one year of HCC coding. Advanced knowledge of medical terminology, anatomy and physiology, major disease processes, and pharmacology. Extensive knowledge of coding conventions and payment rules for medical record documentation and health care reimbursement. Comprehensive understanding and prior experience with ICD-9, ICD-10 and other coding types submitted to the Health Plan. Experience using electronic medical record systems. Ability to manage significant workload and work under pressure to meet deadlines with minimal supervision; strong time management; high accuracy and dependability. Ability to communicate clearly with various stakeholders at all levels of the organization. Strong analytical and mathematical skills; experience in project completion, educational program development, and/or group presentation. Knowledge of the healthcare industry. Physical Requirements Ability to work prolonged periods at a workstation using computer equipment. Ability to travel across the Health Plan service region as needed. Manual dexterity and repetitive motions required. Ability to work in a home office for extended periods as needed for business continuity. Equal Opportunity Employer — Excellus BCBS is committed to an inclusive workplace. We encourage all qualified individuals to apply and provide consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Compensation Range Level I: Minimum $60,410 – Maximum $84,000 Level II: Minimum $60,410 – Maximum $96,081 The salary range represents the minimum and maximum for this position. Actual salary varies by budget, prior experience, knowledge, skills and education, and internal equity. Note: Remote work opportunities may be available on a case-by-case basis. This description lists essential responsibilities and qualifications as required by the Americans with Disabilities Act.
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Join to apply for the
Risk Adjustment Coding Coordinator I/II
role at
Excellus BCBS . 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 medical record review of health plan providers Retrospective medical record review of health plan providers Sole Source and Potentially Unvalidated Diagnosis (PUD) reviews Summary / 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. Prepares and submits adjustments to the appropriate processing / adjustment area (Risk Adjustment/Actuarial Services). Performs vendor QA and sole source PUD coding projects, including over-read assignments. May support 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 utilizing knowledge and experience of ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial Hierarchical Condition Category (HCC) coding, and Medicaid Clinical Risk Groups (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 medical record coding, 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 as established by management. Regularly meets 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 all coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences as required by AHIMA and/or AAPC to maintain professional certification. Presents information from professional activities to 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. Demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and aligning with the Lifetime Way values and beliefs. Maintains high regard for 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) Acts as a liaison between the Plan and designated provider/hospital representatives and vendor(s) for prospective and/or retrospective coding and QA validation reviews, including requesting and retrieving medical records, data element verification, ICD-9/ICD-10 coding validation, monitoring plan specifications, HCC assignment accuracy, and RADV audits. Trains, mentors and supports new employees during the orientation process; serves as a resource to existing staff for projects and daily work. Researches best practices in risk adjustment coding and reviews the professional literature for coding updates; maintains currency in coding. Evaluates, researches, and recommends enhancements to the risk adjustment program. Proposes and develops new desk-level procedures (DLPs) and policies/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 required certification and coding experience, CPC-A or CCA certification 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, organization and time management skills. Able to work independently and within time constraints. Ability to handle confidential health information appropriately. Able to prioritize multiple high-priority tasks. Previous auditing experience desirable. Level II
Minimum Qualifications (in addition to Level I) Minimum of two (2) years coding experience or directly related medical experience, including at least one year of HCC coding. Advanced knowledge of medical terminology, anatomy and physiology, major disease processes, and pharmacology. Extensive knowledge of coding conventions and payment rules for medical record documentation and health care reimbursement. Comprehensive understanding and prior experience with ICD-9, ICD-10 and other coding types submitted to the Health Plan. Experience using electronic medical record systems. Ability to manage significant workload and work under pressure to meet deadlines with minimal supervision; strong time management; high accuracy and dependability. Ability to communicate clearly with various stakeholders at all levels of the organization. Strong analytical and mathematical skills; experience in project completion, educational program development, and/or group presentation. Knowledge of the healthcare industry. Physical Requirements Ability to work prolonged periods at a workstation using computer equipment. Ability to travel across the Health Plan service region as needed. Manual dexterity and repetitive motions required. Ability to work in a home office for extended periods as needed for business continuity. Equal Opportunity Employer — Excellus BCBS is committed to an inclusive workplace. We encourage all qualified individuals to apply and provide consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Compensation Range Level I: Minimum $60,410 – Maximum $84,000 Level II: Minimum $60,410 – Maximum $96,081 The salary range represents the minimum and maximum for this position. Actual salary varies by budget, prior experience, knowledge, skills and education, and internal equity. Note: Remote work opportunities may be available on a case-by-case basis. This description lists essential responsibilities and qualifications as required by the Americans with Disabilities Act.
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