Company :
Highmark Inc.Job Description :
JOB SUMMARY
This job will deliver value to the Health Plan, and its beneficiaries enrolled in Risk Adjusted government programs (MA and ACA), using skills including but not limited to: HCC Coding, medical coding, clinical terminology and anatomy/physiology, CMS coding guidelines, and RADV Audits. Works closely with physicians, team members, Quality, Compliance, partners at Enterprise and leadership to identify and deliver high quality and accurate risk adjustment coding. Supports all RPM risk adjustment projects to comply with all CMS requirements by analyzing physician documentation and interpreting into ICD10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of correct Risk Adjustment coding including documentation improvement, provider education, analyzing reports, and identifying process improvements. Incumbent may also mentor new hires, create training materials, and deliver training by in-person, virtually or webinar venue. Incumbent will conduct data analyses identifying opportunities to improve provider documentation and accuracy of chronic health conditions. Required cross team collaboration for all team projects, including provider outreach, education, and analytics. Conduct Vendor QA and Internal Team QA and assist with oversight. Identify opportunities to improve coder accuracy, prepare and present to team. Directly support department leadership.
ESSENTIAL RESPONSIBILITIES
- Performs HCC coding on projects for MA, ACA, and ESRD. Ability to quickly flex between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models. Ability to work independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures to guide HCC coding decision making. Maintains RPM coding accuracy and productivity requirements.
- Act as mentor on CMS and Highmark Coding Guidelines. Train and mentor new hires. Create, modify, and update training materials. Deliver training on MA and ACA projects to all levels of staff; adapts type to audience; provide constructive feedback; present in-person, virtual, and by webinar. Conduct data analyses from medical record reviews; create specialized provider education by identifying opportunities to improve documentation and accuracy of chronic conditions. Cross functional collaboration in regards to provider outreach for delivery of program performance and appropriate education. Use program analytics and reporting to drive provider engagement for RPM programs.
- Conduct Vendor and Internal Team QA with oversight. Identify opportunities to improve coder accuracy and make educational recommendations in regards to the assignment of ICD10 codes. Make recommendations for QA and Policy updates based on Coding Clinic CMS and industry changes. Conduct research using approved resources to answer questions from the QA Question Queue. Directly support Supervisor, Manager(s), Director(s), Project Managers and RPM interdepartmental teams.
- Assist with Regulatory Audits by performing first coding review and ranking of charts. Build partnerships and work within coding teams and internal partners critical to HCC coding.
- Participate on ad-hoc projects per the direction of Leadership to address the needs of the department. Provide recommendations for process improvements and efficiencies.
- Fully engages in RPM Coding educational meetings and annual coding Summit.
- Other duties as assigned.
EDUCATION
Required
- Associate's degree
Substitutions
-
3 years of relevant work experience with Coding and/or Healthcare
Preferred
- Bachelor's degree
EXPERIENCE
Required
- 7 years of HCC Coding and/or Healthcare
Preferred
- 10 years with HCC Coding and/or Healthcare
- 3 years with RADV Audit
- 3 years with Coding QA Experience
- 3 years as LPN or RN
- 1 year in Management
LICENSES or CERTIFICATIONS
Required (any of the following)
- Certified Professional Coder (CPC)
- Certified Risk Coder (CRC)
- Certified Coding Specialist (CCS)
- Registered Health Information Technician (RHIT)
Preferred
- None
SKILLS
- Critical Thinking
- Attention to Detail
- Written and Oral Presentation Skills
- Written Communications
- Communication Skills
- Benefit Coding
- MS Word, Excel, Outlook, and PowerPoint
- Microsoft Office Suite Proficient - MS365 and Teams
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Remote Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
No
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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