Excellus BCBS
Overview
Join to apply for the
Risk Adjustment Coding Coordinator I/II
role at
Excellus BCBS . Responsibilities for this role include decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position covers 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 Job Description:
Responsibilities
The Risk Adjustment Coding Coordinator is responsible for various aspects of decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position is responsible for risk adjustment coding and quality assurance validation for the following 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
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 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.
Assist 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.
Coordinate with vendors, providers and hospital Medical Records Departments to access and review medical records in a timely fashion.
Meet or exceed productivity targets and meet due dates as assigned.
Ensure activities follow applicable coding guidelines, NYS law, and federal regulations.
Provide peer-to-peer guidance, support coder training and orientation as requested by leadership.
Maintain accuracy in coding and reimbursement methods; engage in ongoing professional development as required by AHIMA and/or AAPC to maintain certification. Share learnings with management and staff as applicable.
Keep management informed of project activities; proactively identify risks that may hinder success.
Demonstrate integrity aligned with company values and protect member privacy per corporate policies.
Regular and reliable attendance is expected.
Performs other functions as assigned by management.
Level II (in Addition To Level I)
Acts as liaison between Plan, provider offices/hospitals, and vendor representatives for prospective and/or retrospective coding and quality assurance validation reviews.
Trains, mentors and supports new employees; functions as a resource to existing staff.
Researches best practices in risk adjustment coding and evaluates coding literature; recommends program enhancements.
Proposes and develops new desk-level procedures and policies; reviews and updates existing procedural documents.
Establishes and maintains a repository for department documentation.
Provides recommendations for process improvements, root-cause analysis, and barrier resolution related to Risk Adjustment initiatives.
May assist or lead projects and handle higher volume than Level 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 experience, CPC-A or CCA may be accepted.
High school diploma required.
Knowledge of medical terminology, medical coding methodologies (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; analytical, organizational and time management skills.
Ability to work independently and under time constraints; ability to handle confidential health information.
Ability to prioritize multiple high-priority tasks; previous auditing experience desirable.
Level II
Minimum of two (2) years coding experience or 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 related to documentation, billing, and reimbursement.
Experience with ICD-9/ICD-10 and other coding used by contracted facilities and providers.
Proficiency with electronic medical records systems; strong workload management and accuracy.
Strong communication skills; ability to work with diverse stakeholders.
Knowledge of the healthcare industry and project execution experience.
Physical Requirements
Ability to work at a workstation for extended periods; use of computer, keyboard and mouse.
Ability to travel across the Health Plan service region as needed.
Equal Opportunity Employer
Compensation Range(s)
Level I: Minimum $60,410 - Maximum $84,000
Level II: Minimum $60,410 - Maximum $96,081
Note: There may be opportunity for remote work on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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Join to apply for the
Risk Adjustment Coding Coordinator I/II
role at
Excellus BCBS . Responsibilities for this role include decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position covers 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 Job Description:
Responsibilities
The Risk Adjustment Coding Coordinator is responsible for various aspects of decision-making and implementation of medical coding reviews and coding policies to ensure accurate diagnosis coding. This position is responsible for risk adjustment coding and quality assurance validation for the following 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
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 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.
Assist 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.
Coordinate with vendors, providers and hospital Medical Records Departments to access and review medical records in a timely fashion.
Meet or exceed productivity targets and meet due dates as assigned.
Ensure activities follow applicable coding guidelines, NYS law, and federal regulations.
Provide peer-to-peer guidance, support coder training and orientation as requested by leadership.
Maintain accuracy in coding and reimbursement methods; engage in ongoing professional development as required by AHIMA and/or AAPC to maintain certification. Share learnings with management and staff as applicable.
Keep management informed of project activities; proactively identify risks that may hinder success.
Demonstrate integrity aligned with company values and protect member privacy per corporate policies.
Regular and reliable attendance is expected.
Performs other functions as assigned by management.
Level II (in Addition To Level I)
Acts as liaison between Plan, provider offices/hospitals, and vendor representatives for prospective and/or retrospective coding and quality assurance validation reviews.
Trains, mentors and supports new employees; functions as a resource to existing staff.
Researches best practices in risk adjustment coding and evaluates coding literature; recommends program enhancements.
Proposes and develops new desk-level procedures and policies; reviews and updates existing procedural documents.
Establishes and maintains a repository for department documentation.
Provides recommendations for process improvements, root-cause analysis, and barrier resolution related to Risk Adjustment initiatives.
May assist or lead projects and handle higher volume than Level 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 experience, CPC-A or CCA may be accepted.
High school diploma required.
Knowledge of medical terminology, medical coding methodologies (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; analytical, organizational and time management skills.
Ability to work independently and under time constraints; ability to handle confidential health information.
Ability to prioritize multiple high-priority tasks; previous auditing experience desirable.
Level II
Minimum of two (2) years coding experience or 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 related to documentation, billing, and reimbursement.
Experience with ICD-9/ICD-10 and other coding used by contracted facilities and providers.
Proficiency with electronic medical records systems; strong workload management and accuracy.
Strong communication skills; ability to work with diverse stakeholders.
Knowledge of the healthcare industry and project execution experience.
Physical Requirements
Ability to work at a workstation for extended periods; use of computer, keyboard and mouse.
Ability to travel across the Health Plan service region as needed.
Equal Opportunity Employer
Compensation Range(s)
Level I: Minimum $60,410 - Maximum $84,000
Level II: Minimum $60,410 - Maximum $96,081
Note: There may be opportunity for remote work on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
#J-18808-Ljbffr