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Role Description

This role involves performing retrospective and prospective chart reviews to ensure accurate risk adjustment reporting.

• Verifies and ensures the accuracy, completeness, specificity, and appropriateness of provider-reported diagnosis codes based on medical record documentation.
• Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC categories.
• Identifies trends in provider coding and documentation and partners with Provider Education Consultants to develop intervention strategies.
• Supports and actively participates in process and quality improvement initiatives.
• Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.
• Consistently meets departmental performance and attendance requirements.
• Serves as a mentor to Risk Adjustment Auditor I staff.
• Assists with special projects such as risk mitigation reviews.
• Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.
• Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program and assists with implementation activities as a result of regulatory changes to the Program.

Qualifications

• Associate degree in Healthcare or related field
• Three years of experience in clinical coding or auditing or equivalent combination of education and experience
• Coding Certification (CCA, CCS, CCS-P, CPC, or CPC-P) required
• RADV, Risk Adjustment, HCC or Inpatient coding experience preferred

Requirements

• Demonstrated ability to perform accurate and complete chart reviews for risk adjustment
• Knowledge of and adherence to Official ICD-9-CM/ICD-10 Coding Guidelines
• Demonstrates analytical ability to identify problems, develop solutions, and implement actions in a timely manner
• Demonstrated ability to identify and communicate trends in provider coding and documentation
• Demonstrated proficient PC skills and familiarity with corporate software, such as Word, Excel, and Outlook
• Effective verbal and written communication skills
• Knowledge of health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products
• Advanced knowledge and understanding of risk adjustment, coding and documentation requirements
• Demonstrated ability to provide proactive and creative solutions to business problems

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits
• Annual employer contribution to a health savings account
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period)
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave)
• Award-winning wellness programs that reward you for participation
• Employee Assistance Fund for those in need
• Commute and parking benefits