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Form of workJob Description
POSITION SUMMARY
This role contributes to Health First Health Plans' (HFHP) Risk Adjustment data collection, supporting compliance with regulatory and contractual requirements specific to Medical Advantage (MA) and Individual and Family (IFP) lines of business. This individual will ensure the integrity of HFHP Risk Adjustment data by critically analyzing and identifying supplemental Risk Adjustment diagnoses through medical record review.
PRIMARY ACCOUNTABILITIES
1. Conduct medical record review for the purpose of identifying and submitting documented diagnosis codes to the Centers for Medicare & Medicaid Services (CMS).
2. Assist in process improvements that will maximize Risk Adjustment factor increases and avoidance of inaccurate MA and/or IFP plan payments.
3. Review of qualified medical records with documentation to include coding of ICD-10-CM codes to validate Risk Adjustment data for the MA and/or IFP lines of business.
4. Maintain national standards for ICD-10-CM coding guidelines including quantity and accuracy standards.
5. Gain a thorough understanding of the Risk Adjustment payment methodology, submission requirements and their impact to the Health First Health Plans payments.
6. Regularly participate in feedback sessions and coding education updates.
7. Remain current on diagnosis coding guidelines and Risk Adjustment reimbursement reporting requirements.
8. Maintain reliability and a commitment to meeting tight deadlines.
9. Sustain personal discipline to work remotely without direct supervision.
10.Maintain knowledge of HIPAA, recognizing a commitment to privacy, security and confidentiality of all medical chart documentation.
11.Take initiative to establish priorities, coordinates work activities and perform multiple and complex tasks while working independently.
Qualifications:
MINIMUM QUALIFICATIONS
• Education: High School/GED
• Licensure: None required
• Certification: Certified Professional Coder (CPC) from AAPC or Certified Coding Specialist (CCS) from AHIMA (will be required during first year of employment).
• Work Experience: 1 year of related healthcare work experience
• Work Experience in lieu of Education: N/A
• Knowledge/Skills/Abilities:
o Excellent verbal and written communication skills including the ability to interact professionally with all levels of the organization. Strong analytical and problem solving abilities.
o Ability to handle multiple tasks and meeting deadlines in a fast-paced, stressful environment. In order to successfully complete their job responsibilities, analysts may be permitted to work from their home while observing current policy.
o Proficient in Microsoft Office products, including Word, Excel, Access, and PowerPoint. Microsoft Access preferred.
o Knowledge and understanding of Federal Medicare program, Medicare Advantage Plans, Individual and Family Plans, and the medical insurance industry in general.
o Ability to read, analyze and interpret professional/legal/medical documents, policies and procedures, government regulations, legislative issues and legal documents.
o Ability to work independently with minimal supervision.
PREFERRED QUALIFICATIONS
• Education: Bachelor's degree in relevant field
• Licensure: No additional required
• Certification: Professional Academy for Health Management (PAHM) certification
• Work Experience: 1 year of HCC coding work experience
• Knowledge/Skills/Abilities: No additional required
PHYSICAL REQUIREMENTS
• Majority of time involves sitting or standing; occasional walking, bending, stooping
• Long periods of computer time or at workstation
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks
• Workspace may vary from open to confined; on site or remote
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle
POSITION SUMMARY
This role contributes to Health First Health Plans' (HFHP) Risk Adjustment data collection, supporting compliance with regulatory and contractual requirements specific to Medical Advantage (MA) and Individual and Family (IFP) lines of business. This individual will ensure the integrity of HFHP Risk Adjustment data by critically analyzing and identifying supplemental Risk Adjustment diagnoses through medical record review.
PRIMARY ACCOUNTABILITIES
1. Conduct medical record review for the purpose of identifying and submitting documented diagnosis codes to the Centers for Medicare & Medicaid Services (CMS).
2. Assist in process improvements that will maximize Risk Adjustment factor increases and avoidance of inaccurate MA and/or IFP plan payments.
3. Review of qualified medical records with documentation to include coding of ICD-10-CM codes to validate Risk Adjustment data for the MA and/or IFP lines of business.
4. Maintain national standards for ICD-10-CM coding guidelines including quantity and accuracy standards.
5. Gain a thorough understanding of the Risk Adjustment payment methodology, submission requirements and their impact to the Health First Health Plans payments.
6. Regularly participate in feedback sessions and coding education updates.
7. Remain current on diagnosis coding guidelines and Risk Adjustment reimbursement reporting requirements.
8. Maintain reliability and a commitment to meeting tight deadlines.
9. Sustain personal discipline to work remotely without direct supervision.
10.Maintain knowledge of HIPAA, recognizing a commitment to privacy, security and confidentiality of all medical chart documentation.
11.Take initiative to establish priorities, coordinates work activities and perform multiple and complex tasks while working independently.
Qualifications:
MINIMUM QUALIFICATIONS
• Education: High School/GED
• Licensure: None required
• Certification: Certified Professional Coder (CPC) from AAPC or Certified Coding Specialist (CCS) from AHIMA (will be required during first year of employment).
• Work Experience: 1 year of related healthcare work experience
• Work Experience in lieu of Education: N/A
• Knowledge/Skills/Abilities:
o Excellent verbal and written communication skills including the ability to interact professionally with all levels of the organization. Strong analytical and problem solving abilities.
o Ability to handle multiple tasks and meeting deadlines in a fast-paced, stressful environment. In order to successfully complete their job responsibilities, analysts may be permitted to work from their home while observing current policy.
o Proficient in Microsoft Office products, including Word, Excel, Access, and PowerPoint. Microsoft Access preferred.
o Knowledge and understanding of Federal Medicare program, Medicare Advantage Plans, Individual and Family Plans, and the medical insurance industry in general.
o Ability to read, analyze and interpret professional/legal/medical documents, policies and procedures, government regulations, legislative issues and legal documents.
o Ability to work independently with minimal supervision.
PREFERRED QUALIFICATIONS
• Education: Bachelor's degree in relevant field
• Licensure: No additional required
• Certification: Professional Academy for Health Management (PAHM) certification
• Work Experience: 1 year of HCC coding work experience
• Knowledge/Skills/Abilities: No additional required
PHYSICAL REQUIREMENTS
• Majority of time involves sitting or standing; occasional walking, bending, stooping
• Long periods of computer time or at workstation
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks
• Workspace may vary from open to confined; on site or remote
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle
