• Job Description

  Req#: 2210278
  Job Type
  
  Contract
  
  Description
  
  Mass Advantage is a Medicare Advantage health plan, located in Worcester, MA. We are affiliated with the largest health care system in Central Massachusetts, UMass Memorial Health. They are the clinical partner of the University of Massachusetts Chan Medical School, with access to the latest technology, research and clinical trials.
  
  We are seeking a Contract (1099) HCC Coding & Risk Adjustment Specialist . This position will require 10 hours per week with the possibility for more hours during weeks with increased volume.
  
  This individual will interpret clinical and diagnostic documentation to determine the opportunity for Hierarchical Condition Category (HCC) diagnosis selection, suspecting and/or removal in accordance with official coding guidelines for prospective and retrospective reviews.
  
  Essential Duties and Responsibilities:
  
  • Serve as subject matter expert and use professional discretion in determining and auditing Hierarchical Condition Categories.
  • Utilize critical thinking skills and clinical reasoning to identify, clarify and query, ensuring that representation of documentation accurately reflects appropriate clinical patient status.
  • Perform comprehensive prospective (pre-visit) reviews and retrospective (post-visit) reviews.
  • Ensure full utilization of available resources as appropriate, such as medical professionals, CMS risk adjustment algorithm and AHA/AHMA coding guidelines.
  • Analyze medical records and encounter documentation to determine appropriate ICD-10-CM (current edition) codes as defined by official coding guidelines and other recognized reference materials.
  • Evaluate clinical records and make determination on necessary documentation and coding inferences and work with medical professionals to confirm determination as necessary.
  • Escalate unusual or questionable situations, coding irregularities, or trends contrary to policies/procedures and recommend corrective measures.
  • Manage a coding accuracy rate of not less than 95% for optimal reimbursement as well as department productivity standards as outlined in department policies.
  • Adhere to the coding and billing regulations established by the American Hospital Association (AHA), American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS).
  • Lead regular communications with other coding personnel to maximize overall effectiveness and efficiency of the operation.
  • Attend required training classes and coding in-services each year to stay abreast of new regulations and coding guidelines.
  
  Prospective (Pre-Visit) Reviews
  
  • Perform comprehensive review of medical records prior to visit including but not limited to physician notes, lab results, hospital records, imaging, and prescriptions to surface potential opportunities and clarification in documentation to be assessed or reviewed during visit.
  • Accurately and thorough entry of appropriate details into Epic pre-visit workflow notification to prepare physicians and practice for upcoming appointments.
  • Collaborate with medical professionals and business partners as needed.
  • Track notifications and response per workflow.
  
  Retrospective (Post-Visit) Reviews
  
  • Perform comprehensive review of encounter documentation and determine any HCCs that were supported by documentation within record but not submitted and/or modification and deletion of HCCs where appropriate.
  • Follow up as needed with medical professionals (i.e. query) regarding opportunity for addition, modification, or deletion of HCCs and appropriate information to revise documentation.
  • Track appropriate information per workflow.
  
  
  Requirements
  
  
  • Bachelor's degree or equivalent experience.
  • Certification(s) as Certified Risk Adjustment Coder (CRC) is required.
  • Minimum of three (3) years of HCC and/or outpatient coding experience.
  • Minimum of two (2) years of supporting coding workflows within Epic.
  • Thorough knowledge of risk adjustment payment mythologies
  • Thorough knowledge of ICD-10-CM (current edition)
  • Thorough knowledge of third-party payer requirements as well as federal and state guidelines and regulations pertaining to coding and billing practices.
  • Completion of Medical coding training and medical terminology from an accredited program required.
  • American Health Information Management Association (AHIMA)
  • American Academy of Professional Coders (AAPC)
  • Must fully comprehend HCC capture and recapture financial impact on the organization and develop recommendations to enhance workflows, processes and practice engagement.

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