HCC Risk Adjustment Quality Coding Specialist II

UPMC; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a detail-oriented medical coder to join their quality team. In this role, you will be responsible for reviewing medical records to ensure accurate Hierarchical Condition Category (HCC) diagnosis coding, participating in government audits, and providing support to the internal Risk Adjustment Department. The ideal candidate will have a strong background in medical coding, familiarity with ICD-10-CM guidelines, and the ability to train new team members. This position offers a chance to make a significant impact in the healthcare sector while maintaining high standards of quality and compliance.

Qualifications

• Experience with ICD-10-CM coding and HCC diagnosis codes.
• Knowledge of Medicare and ACA audit protocols and guidelines.

Responsibilities

• Review medical records for accurate HCC diagnosis coding.
• Participate in government audits and ensure compliance with coding guidelines.
• Train new team members on auditing and coding processes.

Skills

ICD-10-CM Coding

Medical Record Review

HCC Diagnosis Coding

Audit Participation

Anatomy Knowledge

Medicare Guidelines

Education

Certification in Medical Coding

Bachelor's Degree in Health Information Management

Job description

Purpose:
Responsible for reviewing medical records for Hierarchical Condition Category (HCC) diagnosis codes for focused claims reviews and government audits. Performs auditing functions including monitoring, and coding of HCC diagnosis codes. Reviews medical record documentation, to ensure the HCC diagnosis code(s) are supported within audit year, utilizing AHA Coding clinics, ICD-10-CM Coding Guidelines, and government regulations. Participates in government audits. Assists with the on boarding, and training of new team members. Provides audit and coding related support to the internal Risk Adjustment Department.

Responsibilities:

• Utilize standard coding guidelines, coding clinics, and government regulations and protocols to verify the appropriate ICD-10-CMS diagnosis code(s) are correctly assigned by internal or external providers, vendors or staff.
• Ensuring the member's Hierarchical Condition Categories (HCC) are supported within the member medical records for the specified audit period or review time frame.
• Participate in government Risk Adjustment Data Validation audits (RADV) conducting research of internal systems verifying member HCC(s) selected for audit meet ICD-10-CM, AHA coding clinics and government regulations, protocols and submission criteria.
• Understanding of Medicare and Affordable Care Act RADV audits, protocols, guidelines, record submission, audit tools and websites.
• Assign accurate principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the member's medical records, utilizing knowledge of anatomy, physiology, medical terminology and pathology.
• Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.
• Review diagnosis codes submitted by internal/external coders/reviewers and corresponding medical record documentation to ensure the recommended diagnosis code and meets governmental agency requirements for submission.
• Identify error trends to determine appropriate training needs and suggest modification to policies and procedures.
• Completion of special projects including focused claims diagnosis codes and/or coding related audit support.
• Assists Team Lead and/or Manager with research, resolution and response of audit errors, vendor questions, and software implementation/development.
• Provide training to new Quality Team Members.
• Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality.