Riskadjprogopscdgcord I - 001400

Excellus Bluecross Blueshield Buffalo , NY 14202

Posted 5 months ago

The Lifetime Healthcare Companies aim to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.


Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.


Under the direction of the Team Leader, Risk Adjustment Program Operations, the Risk Adjustment Coding Coordinator is responsible for various aspects of decision-making and implementation of medical coding reviews and coding policies to ensure accurate revenue to the Health Plan across all geographic regions. This position is responsible for risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

  • Lifetime Health Medical Group retrospective medical record review

  • Medicare in home health assessment

  • Retrospective medical record review of health plan providers

  • Risk Adjustment Data Validation (RADV) Audits

Essential Responsibilities/Accountabilities

All Levels

  • Serves as a coordinator and key business resource for the Risk Adjustment Coding Coordination Team.

  • Serves as a subject matter expert for ICD-9-CM/ICD-10-CM coding, Medicare Advantage and Commercial Hierarchical Condition Category (HCC) coding, and Medicaid Clinical Risk Groups (CRGs).

  • Reviews medical records to determine if specific disease conditions were correctly reimbursed and documented. Reports findings of the data validation review. Prepares and submits adjustments to the appropriate processing / adjustment area (Risk Adjustment, Actuarial Services).

  • Performs vendor Quality Assurance (QA) and internal Revenue Generating (RG) coding projects, including over read assignments. May support vendor discussions and feedback related to quality audit findings. Presents results and learning opportunities to the team.

  • May participate with department members and other operating teams in developing, implementing, evaluating and updating desktop processes, policies and procedures and business rule tools governing the response to Risk Adjustment Data Validation (RADV) Audits, prospective medical record coding, and retrospective medical record coding.

  • Works with vendors, providers and hospital Medical Records Departments and Business Office staff to coordinate medical record access and reviews in a timely fashion.

  • Develops and submits monthly medical coding articles to the Health Plan Connection Newsletter and to the Univera Healthcare Examiner newsletter.

  • Participates in and meets Inter-Rater Reliability (IRR) targets as established by management. Meets or exceeds a predetermined level of coding accuracy.

  • Meets or exceeds productivity targets as established by management. Regularly meets due dates as assigned.

  • Ensures project activities are in compliance with applicable coding guidelines, NYS law, and federal regulations.

  • Provides peer to peer guidance through informal discussion and over read assignments. Supports coder training and orientation as requested by the Risk Adjustment Program Operations Training Manager and Team Leader Risk Adjustment Program Operations.

  • Maintains accuracy in all coding and reimbursement methods by researching literature and attending professional seminars, workshops, and conferences as required by AHIMA and / or AAPC to maintain professional certification. Presents information from professional activities to management and staff as applicable.

  • Keeps management apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.

  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.

  • Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

  • Regular and reliable attendance is expected and required.

  • Performs other functions as assigned by management.

Minimum Qualifications


We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels:

  • Current Coding Certification (CPC, CPC-H, CPC-I, CCS, RHIA, RHIT, etc.) through AHIMA or AAPC with an associate's degree in a health care related field preferred.

  • A minimum of one (1) year coding experience or directly related medical experience

  • Knowledge of medical terminology and disease processes

  • Knowledge of medical coding methodologies, conventions and guidelines (e.g. ICD-9-CM, ICD-10, CPT, HCPC)

  • Familiarity and understanding of CMS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements, preferred.

  • Strong proficiency with Microsoft Office applications (Word, Excel, Access, and PowerPoint)

  • Strong written and verbal communication skills; strong analytical, organization and time management skills required.

  • Prolonged sitting and standing.

  • Able to work independently and within time constraints.

  • Recognizes and properly handles confidential health information.

  • Able to efficiently prioritize multiple high-priority tasks.

  • Previous auditing experience desirable.

Physical Requirements

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

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Riskadjprogopscdgcord I - 001400

Excellus Bluecross Blueshield