Reviews medical record and claims information to identify all appropriate coding based on Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC & HHS-HCC) models
Provides real time support and coordination visiting Primary Care Providers and Care Coordinators for Commercial Risk Adjustment coding education
Develops policies and procedures for system, application and related operational processes in order to ensure optimization and compliance with CMS risk adjustment and Star measurement coding guidelines
Abstract all risk adjusted diagnosis codes from acceptable provider documentation and in accordance with industry standards for coding and reporting.
Adheres to current industry standard, as defined in the ICD-10 guidelines for coding and reporting.
Conducts Provider queries for any documentation inconsistencies within client electronic medical record and/or other query system
Confirms accurate entry of risk adjusted codes into proprietary software or database as defined by project and client scope.
Must be able to maintain 95% accuracy and completeness in ongoing quality assurance reviews as required by internal QA policy.
Uses expert knowledge of CMS-HCC & HHS-HCC Risk Adjustment Model to provide support in forecasting care opportunities within Commercial risk adjustment and Medicare Advantage segments, coding of Diagnosis codes that pertain to HCCs
Provides encounter data reconciliation between CMS and health plan claims detail to ensure accurate risk adjustment payments
Additional duties as necessary to meet CMS guidelines and regulations
Develops and shares guidelines/best practices with internal risk adjustment coders to improve coding documentation techniques.
May develop policies and procedures for system, application and /or related operational processes in order to ensure optimization and compliance with CMS risk adjustment and Star measurement coding guidelines
May pull medical records for our risk adjustment/HEDIS/STARS projects
Helps with special projects within our Risk Adjustment Operations group
Minimum Qualifications
Bachelor’s degree in business administration or Bachelor of Science in Nursing (BSN), health administration, or related field or an equivalent combination of education and experience.
3 years of medical coding experience in a healthcare plan or environment
2 years of experience working in medical information environment (ex. At health plan, provider office, hospital, etc.)
CPC (Certified Professional Coder) or Equivalent
Must obtain CRC within one year of employment
Preferred Qualifications
2 years of risk adjustment coding experience
Experience with MS Excel and MS Project
Risk Adjustment program experience
ICD-10 Proficiency
CRC (Certified Risk Adjustment Coder)
Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.