Risk Adjustment Analyst - HIM OP CDI

About the role

The Risk Adjustment Coordinator will be responsible for analyzing and auditing medical records retrospectively as requested by insurance companies as required by the third party payer under the value care contracts. In addition, the Risk Adjustment Coordinator will be responsible for working the EPIC WQ to reorder the Hierarchical Condition Categories (HCC) conditions in the top 12 for claim generation. The Risk Adjustment Coordinator will complete Pre-Visit Planning reviews daily to improve HCC capture and HCC Persistency.

Responsibilities

• Perform the payer audits as required under the Value Care contracts by performing validation of the providers and researching and responding to information requested by the payer.
• Review the cases in the HCC Edit WQ to determine the HCC’s that need to be reordered in the top 12 diagnoses before releasing on the claim for billing.
• Affix with creation and updating education tip sheets and tools for providers and other clinical and OP CDI staff such as the HCC/RAF Pocket Guide, HCC Coding Tip Sheets by clinical conditions, and relevant information in the Clinical Documentation Handbook.
• Perform pre-visit medical record reviews patient’s upcoming clinic visit to identify conditions captured over the past 2 years that requires refreshing for the current calendar year. HCC conditions that impact HCC Persistency must be documented at least annually. The Risk Adjustment Coordinator creates queries/prompts to the provider according to the process defined and to facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients.
• Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non-clinical staff to expedite the resolution of queries/prompts.
• Utilize software systems such as the PCIC dashboard and reports, excel spreadsheets to ensure accurate data collection both pre-visit and post-visit for reporting KPI metrics and outcomes.
• Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.

Qualifications

• Education Requirements: High school diploma or GED required. Successful completion of the OP CDI Proficiency Test.
• Licensure/Certification Requirements: Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification – CPC (Certified Professional Coder) or CRC (Certified Risk Coder) - ACDIS (Association of Clinical Documentation Improvement Specialists) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license
• Professional Experience Requirements: Minimum of twelve (12) months of OP coding experience or nursing experience in an ambulatory care setting.
• Knowledge/Skills/and Abilities Requirements: Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations. Strong ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, ability to be flexible, and management of multiple priorities. Strong critical thinking and sound judgement in decision-making.

Benefits

Not specified.

Pay

$24.98 - $35.91 per hour (Hiring Range)

Schedule

Full Time

Location of Job

US:NC:Chapel Hill

Work Assignment Type

Remote

Work Schedule

Day Job

Exempt From Overtime

Exempt: No

Legal Employer

NCHEALTH

Entity

Shared Services

Organization Unit

HIM OP CDI

Other Information

Other information: Not specified.