Risk Adjustment Coding Auditor II

Job Summary

The Risk Adjustment Coding Auditor II position is responsible for auditing clinical documentation and coding to assess accuracy and compliance of coding assignments per the clinical documentation for the  various risk adjustment models (Health and Human Services/ Hierarchical Condition Codes (HHS/HCC), Center for MediCare and MediCare Services/Hierarchical Condition Codes (CMS/HCC), Prescription Medicine/ Hierarchical Condition Codes (Rx/HCC) and California Department of Public Health Plus Prescription Medicine (CDPH+Rx) for all lines of business (MediCare, Commercial, MediCal/MediCaid) for optimal HCC capture, and to develop educational training modules and materials.

Duties

Perform routine audits of the Risk Adjustment Coding Specialists II for coding quality, timeliness, completeness and accuracy across all risk adjustment models and lines of business.

Develop and facilitate corrective action plans (CAP) and educational training modules and materials for the Risk Adjustment Coding Specialists II based on the results of the routine audits and compliance updates per regulators and other risk adjustment standards for clinical documentation improvement (CDI) and coding guidelines.

Perform routine audits of plan partner groups (PPGs) and their clinical documentation and code assignments.  Responsible for analyzing the data to identify trends, deficiencies, and opportunities for improvements in clinical documentation and coding quality, accuracy and completeness

Create and implement CDI and coding education for the rollout of the annual wellness visit (AWE) program to PPGs, clinics and providers, and along with rolling out education for any other risk adjustment projects and initiatives.

Perform routine audits of our PPGs performance participation and completeness for our AWE program and all risk adjustment projects and initiatives focusing on clinical documentation and coding education.

Develop and maintain comprehensive audit reports and dashboards to monitor, track and trend coding discrepancies/errors, incomplete clinical documentation along with corrective action plans and recommendations for timely compliance with the Enterprise Risk Adjustment (ERA) department and regulators.

Perform regulatory and compliance coding audits (e.g. Encounter Validation Audit (EDV), Risk Adjustment Validation Audit (RADV), etc.) for all risk adjustment projects and initiatives.

Develop and facilitate educational training modules and materials on all risk adjustment projects and initiatives for our PPG coders, providers and other healthcare professionals on CDI, coding quality and completeness, updates to coding guidelines, changes in risk adjustment models per compliance requirements and guidelines from our regulators and any other risk adjustment standards to ensure maximum capture/re-capture of risk adjustment diagnosis codes for improvements in HCC rates.

Duties Continued

Review audit reports from regulators for developing and implementing educational training modules and materials for corrective action plans and recommendations, along with assisting with the preparation of risk adjustment reports to regulatory governing bodies.

Participate in quality improvement projects and initiatives. and collaborates with ongoing educational training modules for internal and external stakeholders.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 3 years of risk adjustment coding and auditing experience.

Extensive experience with various electronic health record (EHR)/medical records (EMR) with the ability to navigate a variety of EHR’s/EMR’s.

Preferred: 

Experience with risk adjustment software tools and auditing platforms.

Skills

Required:

Strong verbal and written communication skills.

Strong training, facilitation and presentation skills.

Extensive knowledge of ICD-10-CM, CPT and HCPC coding guidelines, CMS Hierarchical Condition Categories (HCC), and Health and Human Services/Qualified Health Plan (HHS/QHP).

Extensive understanding of coding guidelines (CMS, Coding Clinic & CPT Assistant) any applicable federal, state, and county regulations/laws for clinical documentation, coding, and auditing.

Understanding of the various risk adjustment models (CMS/HCC HHS/HCC, Rx/HCC, and CDPS+Rx).

Audit knowledge of clinical documentation improvement (CDI) and coding quality, accuracy and completeness for the following: medical records & various forms of clinical documentation, annual wellness assessment visits/forms and external vendors coding and auditing of medical records & various forms of clinical documentation.

Ability to create educational training modules and materials for clinical documentation improvement (CDI)and coding compliance for various healthcare professionals.

Extensive knowledge of medical terminology, medical abbreviations, anatomy and physiology, pharmacology, pathology and disease processes.

Ability to develop various tools, job aides, etc. for workflow efficiencies with coding and clinical documentation improvement.

Strong knowledge of Microsoft Office Suite.

Preferred:

Ability to serve lead and liaison for regulatory audits with the ability to speak to corrective action plan providing the status on the corrective action plans

Ability to create organizational compliance policies and procedure for clinical documentation improvement (CDI) and coding quality, accuracy, completeness and timeliness.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information