Risk Adjustment Coder - Community Health Options

The Risk Adjustment Coder is responsible for auditing and evaluating medical records to ensure proper coding and thorough documentation of procedures and diagnoses in support of accurate Risk Adjustment scoring. The work of the Risk Adjustment Coder will be conducted in accordance with CMS regulations and guidelines, ICD-10-CM Official Guidelines and Health Options’ Policies and Procedures.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Maintains knowledge of regulations and requirements supporting ACA/Commercial Risk Adjustment programs, including Risk Adjustment Data Validation Audits (RADVs)
• Determines whether Health Options’ Policies and Procedures related to Risk Adjustment are effective, efficient, and in compliance with official regulations and guidelines and recommends updates to Health Options’ Policies and Procedures in support of changes to such regulations and guidelines
• Facilitates the development and implementation of quality assurance processes into the Risk Adjustment programs
• Performs quality audits on medical records to ensure proper coding and documentation
• Supports the development, tracking and completion of required RADV Audit Protocols and required data collection and submission, including collaboration with external and internal partners
• Monitors Risk Adjustment scoring and recommends modifications and corrective actions to improve results
• Identifies any errors in coding and/or deficiencies in provider documentation and makes recommendations for improvements through education initiatives
• Supports the Provider Network Operations team with provider communications and education related to ACA/Commercial Risk Adjustment programs to ensure proper coding and documentation
• Provides ICD-10-CM coding training, as it relates to HCC coding, as requested
• Provides updates on performance metrics as to completion, data quality and scoring accuracy

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• People within Community Health Options are expected to work with integrity, humility, strategic vision, curiosity, and discipline. They must be self-motivated, highly effective and compassionate communicators, effectively working with people and work processes, and actively engaging in continuous process improvement.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• Associate's degree or higher
• Coding Certification required (CPC, CCS, CCS-P, or RHIT; CPC-A or CCA designation is not acceptable)
• 3+ years of recent ACA/Commercial Risk Adjustment/HCC Coding experience preferred
• 2+ years recent experience ICD-10-CM coding with strong attention to detail and high accuracy rate, preferred
• Expert knowledge of ICD-10-CM, CPT, and other specialty system coding guidelines
• Working knowledge of health plan/insurance terminology and concepts preferred
• Strong knowledge of medical terminology