Performs quality reviews on Documentation and CodingStaff to ensure the process of validating medical record documentation, as per ICD-9 CM and CMS Risk Adjustment Data Validation requirements, is maintained. Performs quality reviews on documentation from providers participating with NAMM Medical Management risk adjustment model, ensuring ICD-9 CM and CMS Risk Adjustment Data Validation requirements are followed. Accountable for identification of provider, staff and client development and education and re-education needs as related to quality review outcomes. Further, this position may have responsibility for HEDIS/5STAR quality chart reviews.
- Performs quality audits on Documentation and Codingstaff to ensure compliance with ICD-9 CM guidelines and CMS Risk Adjustment Data Validation (RADV) requirements are followed and maintained and reports outcomes to Supervisor/Manager.
- Documentation and Codingstaff to include: Clinical Coding Nurses, Medical Coders, and Documentation and Coding Processing Coordinator.
- Education to include on-boarding and re-education needs.
- Performs quality audits on providers participating with NAMM Medical Management risk adjustment model to ensure compliance with ICD-9 CM guidelines and CMS Risk Adjustment Data Validation (RADV) requirements are followed and maintained and reports outcomes to the Contracted Physicians Management Department throughout the year.
- Works in conjunction with the Chief Medical Officer / Physician Education Development team, Documentation and Coding Management Team, and Provider Relations Team to report educational needs identified or requested.
- Works with Documentation and Coding Manager in identifying deficiencies, measuring current state, suggesting improvements, implementing change, re-measuring outcomes, and refining as related to total Documentation and Coding process.
- Works with Documentation and Coding Manager in identifying and writing new policies and maintaining existing policies and procedures.
- Communicates with I.T. Department any areas of defects in the Documentation and Coding database, MDX, Provider Portal, and AHA Portal which are identified and tracks through to completion.
- Monitors Team Discussion Board and answers questions after thorough research.
- Posts coding updates to the Team Discussion Board for continued education of all current Documentation and Codingstaff as related to coding quality.
- Creates, maintains, organizes, and coordinates internal and external Documentation and Coding educational tools as needed as well as updating existing tools with Physician Education Development Team, and Provider Relations Team.
Minimum Required Education, Experience & Skills
Preferred Education, Experience & Skills
- Current RN license to practice in the state of CA -or- Foreign Medical Graduate
- CPC certification or proof that certification has been obtained within 9 months from the American Academy of Professional Coders required.
- Two to five years of clinical experience
- Knowledge of CMS-HCC model and guidelines
- Knowledge of ICD-9 CM and guidelines
- Basic computer and data skills including Access, Excel, PowerPoint and Word
- Ability to interact with multiple departments and outside physician groups
- Ability to speak and provide presentations and education to small and large groups alike
- Excellent oral and written communication skills
- Ability and willingness to travel on occasion as determined by business need
- Bachelor’s degree preferred
- More than two years coding experience.
- Additional quality assurance auditing experience