Job Description

Description

: 

JOB SUMMARY

This job will deliver value to the Health Plan, and its beneficiaries enrolled in Risk Adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA), using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (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 Remote Patient Monitoring (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.


ESSENTIAL RESPONSIBILITIES

  • Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works 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.
  • Assists 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.
  • Participates on ad-hoc projects per the direction of Leadership to address the needs of the department. Provides recommendations for process improvements and efficiencies.
  • Engages in RPM Coding educational meetings and annual coding Summit.

  • Other duties as assigned.


    • EDUCATION


    Required

  • None

    • Substitutions

  • None

    • Preferred

  • Associate degree in medical billing/coding, health insurance, healthcare or related field preferred.

    • EXPERIENCE


    Required

  • 3 years HCC coding and/or coding and billing


    • Preferred

  • 5 years HCC coding and/or coding and billing


    • 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
  • HCC Coding
  • MS Word, Excel, Outlook, PowerPoint
  • Microsoft Office Suite Proficient/ - MS365 & 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

    Pay Range Minimum:

    $26.49

    Pay Range Maximum:

    $41.03

    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 any category protected by applicable federal, state, or local law.

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