HCC Coding Quality Auditor

About the position

The HCC Coding Quality Auditor/Educator will facilitate the development and maintenance of HCC coding and audit programs. The programs are designed to accomplish accurate risk adjustment reporting through the complete and accurate assignment of ICD-9-CM and ICD-10-CM codes corresponding to conditions that are considered part of CMS HCC model and are supported in member's medical record. The HCC Coding Quality Auditor/Educator will be responsible for reviewing provider documentation to verify that all MA risk adjustment documentation requirements are met and will deliver education to providers. The reviewed RA information for compliance and educational objectives must be in strict adherence to Official ICD-9-CM and ICD-10-CM Guidelines for Coding and Reporting, AHA Coding Clinic, CMS, and other organizational policies and procedures. The profile of the members in the HCC programs could vary from complex and high-risk patients to healthy members with Triple Aim target, which is a) enhance member experience, b) reduce costs, and c) improve health outcomes.

Responsibilities

• Subject matter expert for accurate and appropriate risk adjustment coding and CMS data validation.
• Create compliance policies and review patient records in accordance with compliance policies and coding guidelines.
• Develop programs and training materials for coding compliance monitoring and clinical documentation improvement (CDI).
• Develop and utilize risk-based audit approach to establish scope of reviews by incorporating patterns and trending analysis.
• Alert the Manager and/or Director of any areas of identified concern.
• Develop workflows to perform quality assurance (QA) auditing.
• Organize/participate in coding reviews/audits of medical records for RA reporting of all supported HCC conditions for submission to CMS.
• Oversee compliance from the coders, vendors, and providers.
• Prep and share feedback with the entities in a timely manner.
• Identify patterns and trends for educational opportunities.
• Responsible for planning, scheduling, and conducting coding audits; and maintaining records of provider or vendor audit results for HCC diagnosis codes.
• Document audit results and present audit findings to the HCC Program team, providers, vendors, and other internal departments in an organized and actionable format.
• Comfortable with educating and training peers and providers on a one-to-one or group basis.
• Create and maintain positive relationships with peers, leadership, IPA/MSOs, affiliate providers, office managers and all other associates internal or external to the organization.
• Maintain up-to-date knowledge and coding credentials, current updates to governmental requirements and plan requirements related to proper coding through continued education, research and reading resource material.
• Other duties as assigned.

Requirements

• Bachelor's degree with relevant coursework or 5 years HCC coding/auditing and diagnostic coding and education experience preferred.
• Experience in a health plan setting preferred.
• Experience in education/training HCC risk adjustment coding and documentation.
• Experience in correct application of M.E.A.T. concepts.
• Current Coding Certification in one or more of the following: CPC, CPC-H, CPC-P, CCS, CCS-P, CCA.
• Valid driver's license, reliable transportation, and insurance required with clean driving record.

Benefits

• Equal Employment Opportunity and Affirmative Action workplace.
• Salary ranges based on California wages.