SUMMARY:

HCC Coding Auditor Senior will perform code audits and abstraction using the Official Coding Guidelines for ICD-10-CM, AHA Coding Clinic Guidance, and in accordance with all state regulations, federal regulations, internal policies, and internal procedures. The HCC Coding Auditor Senior will be involved with activities of quality assurance auditing and risk adjustment code abstraction for the following programs: including but not limited to, Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). This is an onsite position with a remote option.

REQUIREMENTS:

• High School Diploma required or equivalent
• Excellent written and verbal communication skills.
• Ability to drive within assigned areas or overnight travel for internal or external meetings.
• Capacity to attend remote provider meetings day/evening/weekends as needed within assigned regions as defined by manager/leadership.
• At least three (3) years of hospital inpatient/outpatient or medical office coding experience, preferably three (3) years risk adjustment coding experience.
• Prior experience teaching/training others on correct coding guidelines and have the ability to present to large groups of Physicians/Providers.
• Coding certification required through AHIMA or AAPC (at least two of the below):
• Certified Professional Coder (CPC) required
• Certified Risk Adjustment Coder (CRC) preferred
• Certified Coding Specialist for Providers (CCS-P) preferred
• Registered Health Information Management Technician (RHIT) preferred
• Certified Coding Specialist for Providers (CPMA) preferred Certified Coding Specialist for Providers (CDEO) preferred

• Perform Medical Record reviews and audits based on organizational priorities. These can include both prospective and concurrent Clinical Documentation Improvement (CDI) workflows as well as retrospective auditing. Review and audits may lead to the addition, deletion, adjustment, or confirmation of diagnoses for risk adjustment.
• Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation to ensure adherence with CMS (HCC) Risk Adjustment guidelines.
• Perform coding quality audits within multiple EMRs, databases, and/or vendor platforms to support both employed and independent clinic risk adjustment strategies.
• Identifies revenue, reimbursement, and provider educational opportunities while remaining compliant with state and federal regulations.
• Prepare and/or perform auditing analysis and provide feedback on noncompliance issues detected through auditing.
• Complies with all aspects of coding, abides by all ethical standards, and adheres to official coding guidelines.
• Conduct provider education and training regarding risk adjustment to help ensure accurate CMS payment and to improve the quality of care. This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc.
• Provides measurable, actionable solutions to providers that will result in improved accuracy for documentation and coding practices to ensure chronic conditions are recaptured annually
• Ensures that rendered physician services for claim submission and any subsequent payments are as accurate as possible while complying with regulatory guidelines including CMS, DHS, and OIG
• Assist coding leadership by making recommendations for process improvements to further enhance coding quality goals and outcomes
• Provides measurable, actionable solutions to providers that will result in improved accuracy for documentation and coding practices to ensure chronic conditions are recaptured annually
• Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current ICD-10-CM manual and other relevant material