The Risk Adjustment Coder is responsible for pre-visit chart audits on patients eligible to participate in a Medicare Shared Savings program with their PCP. The Risk Adjustment Coder will review patient charts and documents in the EMR to ensure appropriate and accurate ICD-10 selection, to include the highest level of specificity, acuity, chronicity and documentation, validation, compliance with ICD-10 coding guidelines, and quality of care opportunities based on current and historical documentation and clinical guidelines prior to the encounter.
The Risk Adjustment Coder will prospectively review all available medical records to ensure documentation accurately reflects and supports code selection based on the ICD-10 coding guidelines, which are submitted to CMS for reimbursement based on the CMS Hierarchical Condition Categories and RAF programs for Medicare Risk Adjustment reimbursement initiatives. The Risk Adjustment Coder will highlight potential diagnoses in a physician query as applicable.
The Risk Adjustment Coder will work with the Wellvana Compliance officer to ensure all HIPAA standards are met to protect PHI. The Risk Adjustment Coder will maintain current knowledge on coding and reimbursement requirements for CMS programs as well as ensures compliance with all applicable Federal and State laws and regulations related to coding and documentation guidelines for Risk Adjustment.
Essential Duties and Responsibilities:
Must be able to work on-site or remote based on market need as necessary audits may crossover to other cities.
Work closely with all Wellvana clinic providers to ensure accuracy of codes and diagnoses to capture the true picture of the patients acuity and risk status.
Work directly with Wellvana Leadership to develop ACO-driven processes;
Designing the Wellvana process to effectively communicate with clinic providers, support and data resources, to identify patients with high risk and rising risk conditions;
Assisting to implement a potential market-wide capture mechanism for all MSSP patients,
Working with the CEO and leadership to cost-effectively achieve the stated goals and objectives, working towards a mutually agreed-upon timeline.
Knowledge, Skills & Abilities:
Risk Adjustment methodology experience preferred
Proficient knowledge of CMS-HCC Model and guidelines
Ability to interpret, analyze and abstract data/documentation
Ability to identify HCC improvement opportunities and provide feedback to physicians on proper clinical documentation, compliance, and coding guidelines
Excellent organization and problem-solving skills required. Strong oral and written communication skills required.
Strong time management skills required.
Ability to work in a continuously changing environment.
Must possess a high degree of accuracy, efficiency and dependability. Ability to work effectively as a team member.
Education / Experience Required:
Must have a minimum of 3 years coding experience with at least 1 year HCC Risk Adjustment experience and successful completion of a coding certificate
High School diploma or equivalent required.