Healthcare - Medical Coder III

Metaintro, Inc.; Morgan Hill (CA); Hybrid; USD 80,000 - 110,000; Full time

Benefits offered by this job

Two monitors provided

Laptop provided

Headset supplied

Job summary

Metaintro, Inc. is seeking a remote Risk Adjustment Auditor with 5+ years of experience in CMS/HHS RADV reviews. You will review medical records for HCC support, ensure coding accuracy, and work with client Medical Directors on complex codes.

Requirements include CRC certification through AAPC/AHIMA, strong Excel skills, and knowledge of ICD-10 guidelines. Remote role with national scope; equipment provided (two monitors, laptop, keyboard, mouse, headset).

Qualifications

• 5-7 years in professional coding experience, hospital or related setting.
• Knowledge of insurance claims processing.

Responsibilities

• Reviews unlisted procedure codes to determine if a more specific code exists.
• Provides pricing information to client Medical Director regarding unlisted codes.
• Conducts meetings with state clients to discuss procedure code coverage and ensures coding decisions are implemented.
• Archives all Procedure Code Workgroup agendas, minutes and related materials.
• Maintains HIPAA reason and remark code lists and shares updates with the HIPAA Code Workgroup.
• Supports Claims by working edit reports as assigned.
• Communicates coding issues and updates to Providers to ensure timely claim payments.
• Maintains a library of code books and resources for personnel.

Skills

CRC Certification

Risk adjustment auditing

CMS RADV experience

HCC review

Excel skills

ICD-10 guidelines

Medicare Advantage

ACA familiarity

Education

Bachelor's degree or equivalent

Tools

MS Excel

Job description

Will this role be fully remote?: Yes
Are there any specific locations the candidates should be in (i.e., do they need to live in IL): Any Molina approved states
What is the expected schedule (include dates/time/time zone): 7-4pm or 8-5pm local time M-F.
What are the day-to-day job duties?: Abstract and review inpatient and outpatient medical records for (Hierarchical Condition Categories) HCCs to determine if the HCC is supported by the medical record documentation. Knowledge of ICD-9 ICD10 Official Coding Guidelines, AHA Coding Clinic, including Codling clinic clarifications for DOS year under review. CMS RADV Medical Reviewer Guidance (1/10/2020).
Top Skills Required: Must have prior experience with CMS Contract Level Risk Adjustment Data Validation Audits (RADV) and HHS RADV audits and IPM audits. Must have prior vendor coding review experience. Must have the ability to complete chart review production requirements. Must be experienced in risk adjustment auditing. Must possess valid Certified Risk Adjustment Coder credential through AAPC. Must have 5+ years of risk adjustment auditing experience with a focus on CMS and HHS RADV reviews.
What additional IT equipment is required outside of a laptop/headset/mouse/keyboard (i.e., dual monitor & docking station or single monitor & connecting cables – note these will be billed back to Molina at cost): Two monitors, one laptop, keyboard, mouse, headset.

• Must have a Certified Risk Adjustment Coder certification (CRC) through AAPC or AHIMA
• Will need to maintain a 95% or better coding accuracy performance
• Adherence to coding accuracy and productivity policy and procedure regarding diagnosis code completeness and data entry in each coding accuracy review
• Evaluate each medical record to ensure M.E.A.T. criteria support the existence of all submitted diagnosis codes
• Review supplied medical records to determine if diagnosis codes mapping to HCCs meet CMS and HHS documentation guidelines
• Must have intermediate/advanced Microsoft Excel skills
• Well versed in ICD-10 Official Coding Guidelines, AHA Coding Clinic and any Coding Clinic Clarifications for DOS year under review
• Should have prior CMS RADV contract level audit and HHS RADV coding experience
• Should be familiar with Medicare Advantage and ACA lines of business

Summary

Serves as the primary resource for medical coding updates and information. Advises client on coding issues, provides in-depth research on new or unusual procedures, and makes recommendations when appropriate. Provides support to the Claims and Provider Relations Departments.

Essential Functions: Duties and Responsibilities

• Reviews and researches billed unlisted procedure codes to determine if a more specific code exists.
• Supplies cover and pricing information to client Medical Director regarding unlisted codes.
• Conducts meetings with state client to discuss procedure code coverage and ensures coding decisions are implemented.
• Responsible for archiving all Procedure Code Workgroup (PCW) agendas, minutes, and related materials.
• Maintains HIPAA reason and remark code lists and provides code updates to the HIPAA Code Workgroup, when necessary.
• Supports the Claims Department by working edit reports as assigned.
• Provides Provider Relations with coding issues and updates to be shared with providers to ensure timely and accurate claim payment.
• Maintains a library of code books and relevant resources to be available to personnel, when necessary.
• Serves as a resource for the client and co-workers with question related to coding issues.

Knowledge/Skills/Abilities

• Proficient in MS Office Suite
• Ability to work independently, with minimal supervision
• Excellent verbal and written communication skills
• Ability to abide by Molinas policies
• Ability to maintain attendance to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

Required Education

Bachelors Degree or equivalent experience

Required Experience

5-7 years in professional coding experience, professional or hospital. Knowledge of insurance claims processing.

Required Licensure/Certification

CRC (Certified risk adjustment coder certification through AAPC or AHIMA