Risk Adjustment - Risk Adjustment Coding Analyst 135-2014

Risk Adjustment - Risk Adjustment Coding Analyst 135-2014 CommunityCare Tulsa, OK Job Details Full-time 12 hours ago Qualifications Affordable Care Act (ACA) Data integrity assurance Regulatory compliance evaluation Medical claims processing Health data analysis Medicare EHR systems Health risk assessments Managed care organization experience Word processing CMS Performance Reporting AHIMA Healthcare documentation compliance audits Metrics Reporting Mid-level Data summary reports Medical coding in outpatient clinics Audit Reporting CMS regulatory compliance Retrospective medical coding audits Health insurance knowledge Medicare regulations Continuous improvement Health information data integrity Medical record retrieval Centers for Medicare & Medicaid Services (CMS) billing regulations Clinical documentation improvement Productivity software Data validation Full Job Description

JOB SUMMARY

This role will report directly to the Supervisor of Clinical and Risk Coding and is responsible for clinical and risk adjustment audits for both Medicare Advantage and ACA Programs. Ensuring accurate and appropriate documentation. Audits include Vendors, provider groups, and individual providers. Will also provide medical coding support and HEDIS assistance to the Reporting department. This role will support all seasonal and ad-hoc project assignments for both clinical and risk adjustment.

KEY RESPONSIBILITIES

Ensure ICD codes submitted to CMS for the Risk Adjustment Payment System are accurate, appropriate, and supported by written clinical documentation in accordance with all federal and state regulations. Adhere to all official coding rules and CMS guidelines for risk adjustment programs. Ensure accuracy, completeness, specificity, and appropriateness of diagnosis information. Surveillance of CPT, CMS, and other regulations and their impact related to coding and other business functions. Risk Adjustment Validation Audits (RADV), conduct chart review of inpatient and outpatient medical records for Hierarchal Condition Category (HCC) coding. Review results of risk adjustment audits to identify coding patterns and provide the information back to the supervisor. Provide accurate data results/reports of provider claims and clinical notes audited. Recommend general and specific education topics based on CMS/HHS guidelines to the supervisor in written form (e.g., email, word, etc.) Meet with the supervisor to discuss potential education with the provider groups and other stakeholders to provide coding education and support. Assist with the annual HEDIS medical record review process. Receives assignment to evaluate Medicare Wellness Visit documentation for accuracy and completeness in addressing gaps in care and expiring HCCs. Present findings to the supervisor on a regularly scheduled basis. Perform evaluation /prioritize results of new Medicare Advantage and Marketplace member self-reported health risk assessments for risk adjustment conditions that should be addressed. Create analyses, summary reporting, and coordinate with providers Provide support to health data analysts on medical coding questions and follow up with the supervisor on any issues that need to be resolved. Support medical record requests and retrieval projects. Perform other job-related duties as assigned.

QUALIFICATIONS

Extensive knowledge of ICD, HCPCS, and CPT codes. Knowledge of risk adjustment payment models and risk adjustment coding preferred Familiarity with State and federal regulations governing healthcare preferred Health plan/medical practice experience Medicare Advantage and ACA knowledge preferred Able to work independently and meet stringent deadlines. Strong attention to detail. Possess strong oral and written communication skills Successful completion of Health Care Sanctions background check. Proficient in Microsoft Office applications. Metric Requirements Performance will be evaluated using the following indicators:

Quality Audit Accuracy Rate:

≥ 95-98% coding accuracy

Documentation Defensibility Score:

100% alignment with

MEAT/ICD-10-CM

standards

Compliance Audit Pass Rate:

Minimum threshold set by organization (e.g., ≥ 95%)

Productivity Audit Volume:

25-30 charts/cases per day or week (based on specialty and chart type)

Turnaround Time:

Meets established SLA for completion (e.g., 48-72 hours per batch) Improvement Impact Reduction in

Repeat Findings:

Continuous improvement trend quarter-to-quarter

Timely Remediation Rate:

≥ 90% of corrections and follow-ups completed within the required timeframe

Provider/Coder Feedback Engagement:

Participation in education aligned with audit trends

Financial Integrity RAF Score Accuracy:

Maintains accurate correlation between HCC capture and reimbursement

Lost Revenue Opportunity Reduction:

Identifies and prevents under-coding where compliant and appropriate

EDUCATION/EXPERIENCE

Coding certification nationally recognized by the AAPC or AHIMA is required. Minimum of two years of coding experience utilizing ICD-CM coding required. Experience or familiarity with state and federal regulations governing healthcare. Two years' experience with claims processing systems, coding programs, and electronic medical records preferred. Previous HMO or health insurance experience preferred. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin