This position is responsible for conducting consultative provider outreach services, conducting data analysis and developing and facilitating provider training in support of the implementation and maintenance of risk adjustment based contracting and provider reimbursement modeling. The position assists Network Financial and Health Care Management teams in bench marking and monitoring fluctuations in member and provider risk adjustment scores and the impacts on individual Plan risk scores and the overall company for risk adjusting on and off Exchange products. Performance of duties involves compliance to evolving government payer and regulatory standards.
1) Bachelor degree and 4 years professional consulting experience;
2) Professional speaking or training skills and formal presentation experience;
3) Professional Coder certification and ongoing maintenance of professional coding credential from an accredited academic health information management program or professional coding organization (American Health Information Management Association- AHIMA or American Association of Professional Coders-AAPC or American College of Medical Coding Specialists-ACMCS). Acceptable credentials: RHIA, RHIT, CCS/CCS-P, CPC-P, PCS. (CCA, CPC Apprentice certification or other certificates of coding courses completed not acceptable as certification);
4) ICD-10 coding training;
5) Possess AHIMA ICD10 Train the Trainer certification or obtain within one year of hire;
6) Working knowledge of industry risk adjustment models and related condition category grouping and weighting of clinical conditions by diagnosis/ severity of illness;
7) Analytical skills and knowledge of statistical sampling for audit purposes;
8) Knowledge of health insurance products, managed care operations, and accounting and provider reimbursement principles;
9) Verbal and written communications skills to compose and facilitate training and interpersonal skills to work with internal teams and external providers;
10) PC proficiency including Word, Excel and PowerPoint, including experience with managed care/health insurance systems/databases, and experience with Access or other database development and maintenance experience in support of audit methodology and reporting;
11) Ability and willingness to travel on limited basis, including overnight stays.
PREFERRED JOB REQUIREMENTS:
1) Bachelor degree in health information management, nursing, mathematical, computer science or economics field;
2) CMS Medicare Advantage HCC/ RX-HCC or Medicaid CDPS risk adjustment audit experience;
3) Certified professional auditor (CPMA) credential or HCCA compliance credential (CHC/ CCEP);
4) AHIMA ICD10 Train the Trainer certification and additional coding credentials, such as CCS-H, CPC-H, FCS;
5) SAS or SQL programming experience;
6) Programming or SQL experience or predictive modeling experience.
Multiple positions available.
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