CODER – RISK ADJUSTMENT – Prominence Health Plan – Reno, NV

Job Summary: The Coder of Risk Adjustment will be responsible for accurate coding and documentation which is imperative to support proper reimbursement from Medicare while ensuring organizational compliance. The Coder will perform production coding and coding auditing as well as medical record abstraction in support of the Healthcare Effectiveness Data and Information Set (HEDIS) data collection. Will need
to be well grounded in sound medical coding practices, with experience working in the CMS Medicare Advantage and/or HHS Commercial risk adjustment model. Knowledge of HEDIS data collection is required.

Duties and Responsibilities:

  • Reviews and analyzes patient medical records to ensure compliant and accurate coding.
  • Maintains coding accuracy rate of 95% or greater.
  • Maintains coding productivity of 8 chart reviews/hour.
  • Reviews documentation to determine that all submitted ICD-10 codes are well supported.
  • Provides feedback to the provider for documentation clarification for coding purposes.
  • Performs quality audits on contracted coding vendors to ensure accurate coding occurs.
  • Supports chart review and coding for HEDIS measures (CPT and CPT II coding).
  • Contributes to departmental strategy to provide recommendations to improve organizational coding accuracy and compliance.
  • Maintains and stays up to date on latest coding guidelines, procedures, and policies.
  • Collaborate with team members and maintain conversation on coding guidelines and chart reviews.

Qualifications and Requirements:

  • High School Diploma, GED or equivalent required; Associates degree preferred
  • Minimum one (1) year experience in CMS HCC risk adjustment coding
  • Successful completion of coding certification program (CCS or CPC through AHIMA/AAPC)
  • RHIT and CRC certification preferred.
  • ICD-10 coding proficiency
  • Ability to effectively communicate in English, both verbally and in writing.
  • Proficient in Microsoft Office Suite, Word, Excel and Access
  • Excellent written and oral communication skills
  • Attention to the detail.
  • Billing experience is a plus.
  • Comfortable working in a department with set productivity and coding accuracy standards Experience with NCQA HEDIS programs preferred.
  • Experience working in health care and health
  • Insurance industry. Knowledge of HEDIS data collection is preferred.

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