Responsible for multiple duties in support of Medicare and Medicaid risk revenue management. This includes provider benchmarking and education, mock audit development, medical record retrieval and coding initiatives, and revenue optimization support for Medicare and Medicaid lines of business. The position will analyze trending of diagnosis coding and clinical documentation issues and will engage in the development and delivery of targeted provider education to improve the collection and substantiation of encounter data.
- BA/BS/BSN in Business, Health Administration, Information Systems or Statistics and/or RN/LPN licensure required. Seven (7) to ten (10) years relevant experience and demonstrated proficiency may be substituted for formal education requirement.
- CPC (Certified Professional Coder), CCS, RHIA, or RHIT required.
- Three to five years conducting coding audits and quality performance measures preferred.
- Experience in Health Care Industry, indemnity insurer or similar insurance environment is required.
- Extensive knowledge of ICD-9-CM, CPT, HCPCS, CMS1500, UB04, and other coding guidelines; with knowledge and understanding of CMS HCC Risk Adjustment coding and data validation requirements preferred.
- Demonstrated knowledge of preparation of audit reports preferred.
- Strong understanding of medical terminology, pharmacology, body systems/anatomy, physiology and concepts of disease processes.
- Demonstrated ability to provide effective statistical analysis and analytical problem solving.
- Excellent oral and written communication skills for representation of clear, concise results of completed audit.
- Experience with conducting provider coding and documentation education preferred.
- Solid understanding of CMS-HCC's and Risk Adjustment Processes, including timelines for data sweeps and data integrity requirements for CDPHP’s Medicare Programs preferred.
- Strong provider relationship skills needed.
- Ability to work independently to identify trends in data while proposing solutions for increasing risk scores for plan and individual member levels.
- Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization.
Salary Grade: 16