Health Risk Coding & Education Specialist II (Hybrid - Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

RMRA (Revenue Management Risk Adjustment) Health Risk Coding and Education Specialist - Level II, specific to the Risk Adjustment Coding and Clinical Education team will perform retrospective, concurrent, and prospective chart reviews and audits under direction of the Manager/Lead. Identifies trends and educational opportunities for both administrative and coding/documentation processes. Engages and educates Health Alliance Plan in-network providers.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Auditing of medical records on a concurrent, prospective, and retrospective basis (including all vendor projects) to ensure compliance with applicable coding and documentation standards with an emphasis on diagnosis codes mapping to Hierarchical Condition Category (HCC).
• Assist with all aspects of The Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) mandatory audits including but not limited to coordination, documentation and coding of CMS Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) and vendor service project Risk Adjustment sampling audits.
• Complete appropriate paperwork, project documentation, and system entry requirements regarding claim/encounter diagnosis information for provider medical records, audits, and other special projects. Follow appropriate documentation storage and retention guidelines for all projects.
• Conduct HCC-focused reviews on providers including; tracking results and identifying trends and deficiencies for follow up training. Compile results for reporting to the health plan to assist in targeting deficient providers.
• Year-to-date, month-to-date, and real-time report generation to identify low risk score providers and providers whose HCC reporting is low in comparison to panel size.
• Effectively communicate the audit process and results to the appropriate department provider group and health plan.
• Assists with development of provider educational materials.
• Assists with development of provider education and outreach strategies.
• Completes outreach and engagement activities to the HAP provider network.
• Provides detailed health risk clinical documentation and coding education and training to providers, independent practice associations, vendors and internally within HAP and Henry Ford Health System (HFHS).
• Works with vendors, IPA & Provider offices, operations team and Provider Relations department to secure medical records.
• Maintains current knowledge of official ICD-10-CM coding guidelines, CMS documentation requirements and maintains a clear understanding of regulatory compliance.
• Facilitate workflow of all medical records received and work closely with medical records vendors to obtain medical records before project deadlines.
• Support and participate in process and quality improvement initiatives.
• Participate in continuing education activities to improve knowledge of job performance and to maintain credentialing.
• Abides by the American Health Information Management Association (AHIMA) Standards of Ethical Coding rules and guidelines to ensure high quality health information and accurate data submission to CMS and HHS. Complies with official coding conventions and the official coding guidelines to ensure high quality health information and data submission.
• Works with HAP Compliance Leads.