Compliance Consultant III, Medical Coding - Risk Adjustment

Kaiser Permanente; Pasadena (CA); Vor Ort; USD 90.000 - 120.000; Vollzeit

Zusammenfassung

Kaiser Permanente is seeking a Compliance Consultant III, Medical Coding to independently review records and assign ICD-10-CM codes and related risk adjustment categories. The role includes ensuring documentation supports coding decisions and adherence to regulatory standards, with focus on risk adjustment and compliance across multiple settings.

The position emphasizes collaboration, auditing support, and maintaining defensible coding rationales for internal and external audits.

Qualifikationen

• Minimum two (2) years medical coding experience.
• Bachelor's degree plus minimum three (3) years experience in health care compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field.
• Certified Risk Adjustment Coder from American Academy of Professional Coders OR Certified Coding Specialist from American Health Information Management Association OR Certified Professional Coder from American Academy of Professional Coders

Aufgaben

• Reviews inpatient, outpatient, professional, and supplemental medical records to assign ICD-10-CM diagnosis codes and applicable hierarchical condition categories.
• Validates that each reported condition is documented by an eligible provider, supported by the medical record, captured from an acceptable encounter, and coded in accordance with official guidelines, regulatory requirements, and organizational policies.
• Resolves complex documentation and coding issues, recognizes unsupported or conflicting diagnoses, documents coding rationale, and elevates potential compliance concerns.
• Performs compliance reporting tasks by monitoring, compiling data, identifying risks, and reporting to senior team members on key drivers and performance indicators.
• Assists with auditing assigned lines of business for coding and supports the development of audit result reports and related compliance deliverables

Ausbildung

Bachelor's degree in Health Care Administration, Clinical, Law, Public Health, Business or related field

Jobbeschreibung

Open to candidates residing in any KP authorized state to include CA, OR, WA, CO, GA, VA, HI, MD & D.C.
Please Note: Salary ranges are geographically based. Lower salary ranges will apply for other labor markets outside of NCAL.

The Compliance Consultant III, Medical Coding independently reviews inpatient, outpatient, professional, and supplemental medical records to assign supported ICD-10-CM diagnosis codes and applicable hierarchical condition categories. The coder validates that each reported condition is documented by an eligible provider, supported by the medical record, captured from an acceptable encounter, and coded in accordance with official guidelines, regulatory requirements, and organizational policies. The role requires advanced proficiency in risk adjustment coding platforms, electronic medical records, encoder applications, understanding of documentation cues, and production reporting tools. The Senior Coder is expected to resolve complex documentation and coding issues, recognize unsupported or conflicting diagnoses, document coding rationale, and elevate potential compliance concerns. All coding decisions must be defensible, traceable, and suitable for internal review or external audit.

Job Summary

In addition to the responsibilities listed below, the position is responsible for serving as a compliance subject matter expert related to coding functions within assigned settings of care, maintaining compliance with national coding policies and procedures, assisting with coding questions and related topics, and assisting with auditing assigned lines of business for coding. Additionally, this position is responsible for assisting with the development of audit result reports and supporting compliance and the Principles of Responsibility (KP's code of conduct).

Essential Responsibilities

• Pursues self-development and effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and customers; influencing others through technical explanations and examples; providing occasional mentoring to team members; listening and responding to, seeking, and addressing performance feedback; creating plans to capitalize on strengths and develop weaknesses; anticipating and responding to the needs of others; and adapting to and learning from change, difficulties, and feedback.
• Completes work assignments by applying up-to-date expertise in subject area to generate creative solutions; ensuring all procedures and policies are followed; leveraging an understanding of data, and resources to support projects or initiatives; collaborating cross-functionally to solve business problems; identifying and monitoring priorities, deadlines, and expectations; communicating progress and information; identifying, recommending, and implementing ways to address improvement opportunities; and escalating issues or risks as appropriate.
• Conducts company compliance activities under the guidance of more senior employees by providing support to internal and external stakeholders; applying established regulations and standards to compliance efforts; and documenting compliance activities.
• Assists with compliance reporting efforts by monitoring, and compiling compliance data and information to identify potential risks and remedies; researching, analyzing, and summarizing data; and reporting to senior team members on key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations).
• Assists with compliance investigation efforts by collecting and analyzing data; identifying misalignment with desired compliance actions; conducting interviews as appropriate; determining action steps for resolution; and providing input on corrective action plans.
• Provides support on projects by coordinating stakeholder contacts; assisting in the development, analysis, and coordination of project plans for compliance specific deliverables; and coordinating project schedules and resource forecasts.
• Assists with ensuring regulatory compliance by monitoring regulatory changes; acting on regulatory updates; and supporting the implementation of designated changes.
• Assists in the implementation of compliance efforts by identifying compliance requirements; supporting the assessment of current state compliance to identify gaps and corrective actions; supporting the creation or revision of basic compliance standards, policies and procedures, and training; and monitoring ongoing compliance adherence.

Minimum Qualifications

• Minimum two (2) years medical coding experience.
• Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum three (3) years experience in health care compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field. Additional equivalent work experience in a directly related field may be substituted for the degree requirement.

• Certified Risk Adjustment Coder from American Academy of Professional Coders OR Certified Coding Specialist from American Health Information Management Association OR Certified Professional Coder from American Academy of Professional Coders

Preferred Qualifications

• Two (2) years hospital coding experience.
• Two (2) years coding audit experience.