Lead Coding & Education Specialist (Hybrid - Troy, MI) - Health Alliance Plan
GENERAL SUMMARY:
The Lead Coding and Education Specialist will support the activities that assure compliant coding and documentation by providers. Develops and executes projects concentrated on complete and accurate reporting of the health status of HAP’s Medicare Advantage (MA) and Commercial Qualified Health Plan (QHP) membership to CMS. Leads various projects that assure HAP’s provider community improve with accurate submission of clinical documentation and coding of risk adjustment data through a combination of education and engagement programs and medical chart review and/or auditing activity. Identifies trends and educational opportunities for both administrative and coding/documentation processes. Leads/oversees engagement and education of coding staff Health Alliance Plan in-network providers.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
- Leads and oversees audits projects, chart reviews, RADVs, and provider education for retrospective, concurrent, prospective, audit, compliance, and vendor-driven projects. Become proficient using the Altegra RiskView systems for both Medicare Advantage Risk Adjustment and Healthcare Reform Risk Adjustment as well as the Altegra Alert Portal.
- Develops and implements prospective, retrospective and auditing project strategy to support improved clinical documentation and coding activity and increased compliance of this activity.
- Trains and lead coding and provider education staff and provide lead oversight duties to other contracted staff (including HFMG Population Management, PHS coders, and any outside vendors) working on risk adjustment projects.
- Leads the development of educational activities/materials, outreach and reporting strategies for both providers and coders regarding Risk Adjustment, to increase the understanding of the importance of accurate ICD-9-CM/ICD-10-CM coding and the supporting medical record documentation. Serve as a subject matter expert to internal/external customers regarding MA/QHP risk adjustment and medical record coding.
- Participates in multidisciplinary teams related to risk adjustment work, minimally, the HFHS/HAP MA/QHP Risk Adjustment Work Group, Coding Compliance Work Group, External Vendor HRA oversight, and HFHS In Clinic HRA.
- Develops annual RA Compliance work plan. Work with staff and auditors to verify and ensure the accuracy, completeness, specificity, and appropriateness of diagnosis codes based on medical record documentation and coding compliance. Support tracking of results for Senior Leadership and Corporate.
- In conjunction with the manager and Corporate Compliance Department, for the completion of the CMS Risk Adjustment Data Validation (RADV) audits. Maintain readiness for audits by creating and maintaining a RADV audit plan and annually performing internal audits. Oversee the Risk Adjustment portion of the annual QHP RADV audits.
- Designs, facilitates the implementation, and maintain appropriate processes and control mechanisms to ensure appropriate paperwork / documentation / system entry / storage retention regarding claim / encounter diagnosis information for provider medical records, audits, and other special projects.
- Assures oversight work with vendor.
- Reviews and monitors all HIPAA and CMS regulations for updates and changes pertaining to MA and QHP programs. Determine and implement changes needed for systems and processes.
- Actively targets member/provider populations for retrospective, prospective, concurrent, vendor-driven, and CMS data validation projects for risk adjustment utilizing the Altegra Risk View system and other tools through analysis and problem solving.
- Updates and manages all departmental policies and procedures.
- Leads 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.
- Effectively communicate the audit process and results to the appropriate department provider group and health plan.
- Completes outreach and engagement activities to the HAP provider network.
- Assures operations team, education team and Provider Relations departments secure medical records.
- Maintains current knowledge of official ICD-10-CM coding guidelines, CMS documentation requirements and maintains a clear understanding of regulatory compliance.
- 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
EDUCATION/EXPERIENCE REQUIRED:
- Associates degree in Health Information Management (HIM), Health Information Technology (HIT), healthcare, health service, or public health related field required.
- Bachelor’s degree or equivalent work experience in healthcare, health service or public health related field preferred.
- Minimum of two (2) years of experience working in a coding lead or similar role.
- Minimum of five (5) years of coding experience and proficiency in ICD-10-CM and ICD-9-CM diagnostic and procedural coding.
- Prior experience leading teams or small groups.
- Experience with Excel spreadsheets.
- Experience working with physicians and providers’ office staff.
- Prior healthcare related experience working with physicians/medical groups/physician offices preferred.
- Knowledge of medical billing and third-party payer regulations preferred.
CERTIFICATIONS/LICENSURES REQUIRED:
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) required;
- Certified Coding Specialist (CCS), Certified Coding Specialist –Physician (CCS-P) or Certified Professional Coder (CPC), preferred.
Skills and Abilities:
- Ability to effectively lead a team.
- Ability to communicate complex coding issues and back up approach with support.
- Strong ability to work independently with limited direct supervision.
- Ability to work with automated systems.
- Ability to work across multi-disciplinary teams.
- Ability to plan, coordinate and organize multiple priorities and projects independently.
- Strong work ethic, reliable, resourceful, with enthusiastic attitude.
- Knowledge of Medicare Advantage Risk Adjustment and HHS Commercial Risk Adjustment payment methodologies preferred.
- Knowledge of CMS programs, processes, and payment principles preferred.
- Ability to get results with physicians and physician’s office staff to obtain medical records.
- Excellent communication skills and ability to work well with multiple HAP departments to get desired results.
- Knowledge of the release of health information processes and regulations.
- Knowledge of Health Insurance Portability and Accountability Act (HIPAA).
- Strong knowledge in ICD-10-CM coding and guidelines.
- Excellent quantitative, analytical, and problem-solving skills.
- Excellent written and oral communication skills.
- Strong knowledge of anatomy, physiology, pathophysiology, disease processes, medical terminology, pharmacology, and coding systems.
- Strong knowledge in the use of Microsoft Office products.
- Knowledge of computer software programs used for data collection.
- Knowledge of CMS programs, processes, and payment principles preferred.
- Knowledge of Adobe Pro preferred.
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.