Practice Transformation Specialist

Palm Beach Accountable Care Organization, LLC; Houston (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Palm Beach Accountable Care Organization, LLC seeks a detail-oriented Medical Coder/Risk Adjustment Specialist in the Houston area to optimize coding accuracy and support quality initiatives. You will work closely with physicians and office staff to align documentation with risk adjustment requirements and payer guidelines.

The role emphasizes training, data analysis in Excel, and adherence to HIPAA and regulatory standards, with opportunities to improve reimbursement under MA and related

Qualifications

• High school diploma or GED or related experience.
• Certified coder with MA plans or insurance experience.
• Spanish is a plus.
• MS Office Productivity Tools (Word, Excel, Outlook, PowerPoint); Eclinical Works, Athena or other practice management systems.

Responsibilities

• Manage established physician network for business development and plan/execute healthcare network strategy.
• Consult with physician offices to develop training curriculum for client processes and workflow; map data to new EHR system.
• Review provider documentation to ensure E/M levels are accurate and that ICD-10-CM guidelines are followed.
• Identify risk adjustment opportunities and quality gaps to support cost savings for contracted health plans.
• Provide guidance to staff on coding and billing procedures; assist with training and audits as needed.
• Perform daily reporting and analytics in Excel (pivot tables, trend analysis) to monitor client performance.

Skills

CPC certified

Medical coding

Excel

EHR systems

HIPAA compliance

Communication skills

Education

High school diploma or GED

Certified coder (MA plans/insurance)

Tools

MS Office

Eclinical Works

Athena

Job description

• Manage established physician network for business development through system integration and trouble shooting. Work closely with the company business partners and to plan and execute a winning healthcare network strategy.
• Consults with physician offices to develop training curriculum specific to client process and work flow for optimal use and operation of EHR systems. Analyzes workflow by observing customer operations for three days and configures system to the customer’s workflow. Maps customer’s data from current system to new EHR system.
• Develops customized training plan complying with regulations and practices of physician specialty, state, third party, etc.
• Conducts major training programs which may contain a number of different subject modules requiring the coordination of inter- and intra-organization resources.
• Provides guidance and direction to less experienced educators regarding training and technical problems.
• Works in a collaborative effort directly with physicians and their office staff to review medical records and other clinical documentation to identify appropriate risk adjustment codes and quality gap closure opportunities.
• A major focus of the position is to collect and review documents to support quality and risk adjustment initiatives, which results in improving quality of care, support to contracted health plans in achieving cost saving opportunities.
  Stay current on all insurance policy requirement guidelines and active CPT/HCPCS/ICD-10 codes for all payers relevant to the addiction industry. This will be an ongoing effort.
• Assist with billing claims and collection efforts, as needed
• Create test studies and pilot programs for various coding strategies in effort to maximize reimbursement within all clinical requirements.
• Assist in daily reporting and analytics on assigned clients. The ideal candidate will have expert knowledge and experience in Microsoft Excel with the ability to perform financial analysis through pivot tables and trend analysis. * Monitors team results to ensure they are aligned with departmental goals.
• Participates in special projects and performs other duties as assigned. Present coding guidelines to management and clients, as needed
• Predict industry trends
• Current CPC; experience in coding and has current knowledge and experience with the active changes in Accountable Care or Medicare Advantage industry.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis. * Convey a strong professional image, exhibit interest and positive attitude toward all assigned work. * Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Review provider documentation to assure the appropriate E&M levels are assigned correctly.
• Determine the final diagnoses and procedures stated by the provider are valid and complete. Follow coding guidelines to ensure compliance with Federal and State regulations.
• Communicate effectively with providers and other support staff. Daily verification of insurance eligibility and benefit information.
• Answer patient questions regarding claims and billing matters. Assist with the posting of insurance and patient payments.
• Ensure compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries in order to verify whether
• The diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.
• The diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted timeframe.
• Any diagnosis code that is unsubstantiated by the record should be eliminated.
• Review for clinical indicators and query providers to capture the severity of illness of the patient.
• Orients new providers and monitors their documentation and self-coding until they meet quality standards.
• Provides instruction to providers and staff in abstracting codes effectively from medical records to ensure quality and timely care of our members as well as correct reimbursement.
• Communicates with physicians and office staff on education for risk adjustment.
• Conducts medical charts and claims audits, identifying opportunities for improving individual member risk adjustment score accuracy.
• Must abide to all HIPAA, Confidentiality and Privacy laws.
• Handles customers concerns in a helpful and objective manner.
• Must assist in maintaining area organized, clean.
• Effectively present and manage the unique benefits of company products and services to physician offices.
• Other duties as assigned by your Supervisor and Managers.
• Other duties as assigned

Supervisory Responsibilities

This job has no supervisory responsibilities.

To perform the job successfully, an individual should demonstrate the following competencies:

• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions.
• Safety and Security - Uses equipment and materials properly.
• Attendance/Punctuality - Is consistently at work and on time.
• Knowledge of medical records work procedures.
• Knowledge of computer applications.
• Knowledge of medical terminology.
• Knowledge of legal and ethical consideration related to patient information.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

High school diploma or general education degree (GED); or related experience and/or training preferable; or equivalent combination of education and experience. Certified coder with experience in MA plans or insurance companies. Experience with electronic billing systems.

Language Skills

Ability to read and comprehend simple instructions, correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one situations to visitors, clients, and other employees of the organization. Spanish is a plus.

Reasoning Ability

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.

Computer Skills

MS Office Productivity Tools (Word, Excel. Outlook, PowerPoint) Eclinical Works, Athena or other state of the art practice management systems.

Other Skills and Abilities

High accuracy and extreme confidentiality a MUST. Detailed oriented and very organized. Ability to alphabetize and put information (materials, forms, etc.) into chronological order. Analyze medical records for completeness, schedule time and assignment effectively.

Physical Demands

While performing the duties of this Job, the employee will have a combination of standing, sitting, bending and reaching. May work at a computer monitors for prolonged periods. The employee may lift and/or move up to 10 pounds.