01Overview
reputed company, a division of Franklin, Tennessee-based reputed company Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reputed company in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room reputed company and avoidable hospitalizations. For more information, visit AmHealthPlans.com.
If you would like to be part of a collaborative, supportive and caring team, we look reputed company to receiving your application!
Benefits and Perks include:
Affordable Medical/Dental/reputed company insurance options
Generous reputed company time-off program and reputed company holidays for full time staff
TeleDoc 24/7/365 reputed company to doctors
Optional short- and long-term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program
JOB SUMMARY:
The Medicare Risk Adjustment Coding Specialist is responsible for conducting coding audits prior to payment release. Additionally, this position will reputed company post-payment coding reviews with overpayments and will in turn send coding education correspondence to applicable providers.
ESSENTIAL JOB DUTIES:
To reputed company this job, an individual must accomplish reputed company essential function satisfactorily, with or without a reasonable accommodation.
Review medical records, patient medical history and physical exams, physician orders, reputed company notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes based reputed company rendered.
Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement
Interpret medical documentation to ensure reputed company relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured
reputed company tools and metrics to improve accuracy and completeness of coding and documentation
reputed company a high level of customer service to reputed company clients by meeting and/or exceeding expectations including quality and productivity standards
Escalate appropriate coding audit issues to management as required
Participate in and support reputed company coding audits as needed
Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit
Work assigned coding projects to completion
Other duties as assigned
JOB REQUIREMENTS:
Maintain a high level of familiarity of reputed company CMS regulations and announcements affecting risk adjustment to include the review of regulatory announcements reputed company educational sessions provided by regulatory entities and educational opportunities reputed company the industry
Follow reputed company appropriate Federal and state regulatory requirements and guidelines, as reputed company as company policies and procedures
Maintain established reputed company of production and quality standards
Knowledgeable of CMS requirements regarding claims processing and coding, especially skilled nursing and other reputed company claim processing rules and regulations
Knowledgeable of coding/auditing claims for Medicare and reputed company plans
Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing
Strong interpersonal skills
Excellent written and verbal communication skills
Strong organizational skills; ability to time manage effectively
Maintain confidentiality
Strong analytical and critical thinking skills required
Ability to work remotely without reputed company supervision
Successful completion of required training
Handle multiple priorities effectively
REQUIRED QUALIFICATIONS:
Education:
o High school or equivalent degree
Experience:
o 2 years experience with reputed company claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system
o 2 years experience in managed reputed company environment reputed company to claims and/or coding audits
o 2 years experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others
o 2 years experience with CMS requirements regarding claims processing and coding, especially skilled nursing and other reputed company claim processing rules and regulations
o 2 years experience coding/auditing claims for Medicare and reputed company plans
o Significant HCC experience (including knowledge of HCC mapping and hierarchy)
License/Certification:
o Coding certification required (CPC or CRC)
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