Job Description :
This job works with providers in the areas of Hierarchical Condition Category (HCC) Coding accuracy and Quality/HEDIS for compliant, accurate and complete documentation and submission of claims and other reportings. Knows and recognizes compliant HCC Coding and Quality/HEDIS documentation in patient encounters. Continues education to stay abreast of CMS updates, ICD10 Coding Guidelines and HEDIS measures. Reviews ambulatory and inpatient medical charts in EPIC EHR for prospective and retrospective coding of chronic conditions which map to HCCs, educate providers on Risk Adjustment Coding and Documentation Guidelines and necessary quality of care measures to improve both HCC and care gap closure rates. Recommends and implements process improvements related to provider HCC Coding and Quality/HEDIS care gap closures. Ability to assess provider workflow, analyze provider office processes and recommend improvements; provide specialized professional and confident provider presentations individually and in groups. Travel to provider offices within Western Pennsylvania is required.
- Develop and manage process improvement initiatives from Highmark for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
- Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value based care and achieve and maintain accreditation.
- Educate providers in the area of HCC and Quality measure documentation and coding, and compliant documentation for submission of claims and other reporting. Create and present professional and compliant provider education specialized for the individual provider office.
- Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan and to follow CMS Coding Guidelines.
- Conduct retrospective, concurrent, and prospective, semi-annual and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed.
- Other duties as assigned.
- Associate's Degree in Nursing or Licensed Practical Nurse (LPN)
- 5 years Combined experience in Coding and Healthcare, Quality and HEDIS
- 7 years HCC Coding and Healthcare, Quality and HEDIS
- 5 years Registered Nurse experience
LICENSES or CERTIFICATIONS
- Certified Professional Coder (CPC)
- Certified Coding Specialist (CCS)
- Certified Risk Adjustment Coding Certifications (CRC)
- Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles
- Must be able to communicate with medical administrators, including Medical Directors, Physicians, and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and coding and quality improvements
- Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
- Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data
Language (Other than English)
25% – 50%
PHYSICAL< MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Referral Level Payout 2
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