Healthcare - Medical Coder III

BigR.io; United States; Remote; USD 70,000 - 110,000; Full time

Benefits offered by this job

Two monitors

Laptop

Keyboard

Mouse

Headset

Job summary

BigR.io seeks a Medical Coding Auditor to review inpatient and outpatient records for HCCs, ensuring documentation supports codes under CMS RADV/HHS RADV guidelines. Work is remote in the United States with a 7-4 or 8-5 local schedule Monday–Friday.

Must hold CRC certification and have 5+ years of risk adjustment auditing, especially CMS/HHS RADV experience. Proficiency in ICD-10 guidelines, AHA Coding Clinic, and strong Excel skills are required; prior vendor coding review and familiarity with

Qualifications

• Experience with CMS RADV and HHS RADV audits.
• Vendor coding review experience.
• Ability to meet chart review production requirements.
• Experience in risk adjustment auditing.
• CRC certification through AAPC or AHIMA.
• 5+ years in risk adjustment auditing focusing on CMS/HHS RADV.

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 coworkers with questions related to coding issues.

Skills

CMS RADV & HHS RADV audits

Vendor coding review experience

Chart review production requirements

Risk adjustment auditing

CRC certification

5+ years RADV auditing

Education

Bachelor's Degree or equivalent experience

Tools

Microsoft Excel

Job description

Medical Coding Auditor

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.

Additional IT Equipment

Two monitors, one laptop, keyboard, mouse, headset.

Note: these will be billed back to Molina at cost.

Requirements

• 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

• 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 Molina's 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

Bachelor's 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)