Overview

Coordinates the coding activities to ensure optimization of risk adjustment revenue across VNSNY CHOICE population as prescribed by Center for Medicare and Medicaid Services, Department of Health, Health and Human Services or other State and Federal Regulatory Agencies. Ensures protocol is followed and quality control regarding the coding work done by the coding staff. Also serves as the Business Lead on various projects and activities. Works under general supervision.

Responsibilities
Supervises coding activities for Risk Adjustment Revenue Optimization efforts.Conducts QA coding reviews and provides guidance to ensure accurate documentation and adherence to CMS guidelines.Develops policies and procedures for Risk Adjustment as it pertains to CMS Hierarchical Condition Categories (HCC) coding.Supports clinical and compliance teams to leverage clinical, coding, and documentation expertise to foster improvements in the overall quality, completeness, and compliance of clinical documentation.Supports the creation, maintenance, and enhancement of a culture of best-in-class clinical documentation accuracy in support of building a model of care focused on quality and health outcomes.Participates in and supports the Medicare Risk Adjustment team-based environment to educate providers on coding compliance and consistency.Engages with medical practitioners to provide feedback and educational resources on best practices for medical coding.Supports and manages provider queries to ensure that appropriate documentation appears in the medical record.Maintains data/log of all documentation audits / reviews and conducts ongoing follow-up activities and communication for uncompleted or unanswered queries.Collaborates with Quality Auditor and Compliance teams to assist with analysis, trending, and presentation of audit / review findings, outcomes, and issues.Works with the Medicare Risk Adjustment team and leadership to ensure coding compliance and appropriate reimbursement from CMS.Alerts Quality, Clinical, and Finance leadership of coding trends and irregularities. Conducts chart review of Provider Risk Adjustment Activity and clinical documentation errors around Hierachical Condition Coding (HCC) alerts addressed at date of service.Prepares correspondence and summary reports of coding review; maintains databases and files as necessary.Identifies and communicates documentation deficiencies to providers to improve documentation for accurate risk adjustment coding.Keeps current on new coding and billing guidelines and federal and state initiatives regarding claims.  Educates other departments on new/changes to regulations. Performs all duties inherent in a  supervisory role.  Ensures effective staff training, interviews candidates for employment, evaluates staff performance, and recommends hiring, promotions, salary actions, and terminations as appropriate.Participates in special projects and performs other duties as required.
Qualifications

Licensure:

Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or (CRC) Certified Risk Adjustment Coder in ICD-10-CM coding required.

Education:

Bachelor’s Degree or the equivalent work experience required.

Experience:

Minimum four years of business experience with medical coding and leading projects required.Supervisory or team lead experience required. Experience analyzing business needs and providing solution required.   Working knowledge  of medical terminology, physiology, pharmacology, and disease processes and related procedures required.Strong background in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) Methodologies required. Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements required. Strong knowledge of claims coding and payment methodology, associated with a Health Plan, State, Federal and Medicare Regulations and Coordination of Benefits applications required.Strong planning, organizational, interpersonal, verbal and written communication skills required.Proficiency with Microsoft applications required.Demonstrated ability to work in high paced environment, handling multiple responsibilities and projects required.