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