Risk Adjustment HCC Quality Expert

Responsibilities

• Perform duties and responsibilities in a fashion that coincides with the service management philosophy of UPMC, including the demonstration of the basics of service excellence towards patients, visitors, staff, peers, physicians, and other departments.
• Participate in government Risk Adjustment Data Validation audits (RADV) conducting research of internal systems verifying member HCC(s) selected for audit meet ICD-10-CM, AHA coding clinics and government submission criteria.
• Audit and provide accurate review outcome(s) of principal and secondary diagnoses and procedures by thoroughly reviewing all member’s medical records utilizing knowledge of anatomy, physiology, medical terminology, and pathology.
• Audit and provide accurate review outcome(s) of diagnosis codes from members discharge summaries, history and physicals, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room.
• Complete special projects including focused claims diagnosis codes and/or coding related audit support.
• Communicate effectively with team members, departmental staff, and outside vendors as necessary to address issues and concerns.
• Assists other departments with coding audits/reviews.
• Provide education and audit related feedback to enhance the coding, clinical documentation, and revenue knowledge base of the Quality and Risk Adjustment team.
• Assist with orientation and training for new Quality team members.
• Ensure the member's Hierarchical Condition Categories are supported within the member medical records for the specified audit or review period.
• Serve as the quality audit liaison to third parties whom the Health Plan contracts with for audit support.
• Serve as an expert resource for other health plan departments for questions related to risk adjustment, coding, auditing, and clinical documentation.
• Coordinate, develop and present focused review and government audit summaries to internal and external health plan teams related to risk adjustment, coding, and documentation.
• Identify trends and barriers that interfere with correct coding and documentation practices in the physician practice sites, including but not limited to workflow, electronic health records, and clearinghouses.
• Collaborate with the different Risk Adjustment teams to troubleshoot issues related to medical record documentation, coding, electronic health records, claim submission, identify potential solutions, and work arounds to maximize revenue.
• Maintain a current and in-depth knowledge of CMS guidelines related to risk adjustment, coding, and documentation, as well knowledge of new models of risk adjustment that impact Health Plan revenue.
• Analyze medical record documentation and coding through an audit process that identifies incorrect coding, coding lacking supporting documentation and missed opportunities to capture risk adjustment diagnoses and associated revenue.
• Identify barriers and coding trends that may increase audit risk and provide education to coders, educators, and quality staff to minimize risk.
• Develop audit tools and coding tools and educational offerings for physicians that highlight poor coding and documentation practices that may increase audit risk.
• Serve as a role model, mentor and resource for the Quality Team clinical and coding staff, and other risk adjustment staff, including coders, abstractors, and business analysts.
• Assist in the management of special projects related to auditing, HCC coding, and documentation.
• Collaborate with Quality Assurance, Medicare team and other Health Plan departments as required.
• Effectively prioritize and complete all assigned tasks.

Qualifications

• Bachelor’s Degree in health care management, nursing or related field or an Associate Degree with relevant experience in nursing, coding, coding management, or HCC Risk Adjustment required.
• Master’s degree preferred in nursing, health care administration, or education.
• 10 years of relevant experience in professional services, including practice management, nursing, clinical audit, coding, or physician education required.
• Progressive leadership experience preferred.
• Coding certification in two or more of the following will be required: CCS, CCP, CRC, CPC, CPC-P, CPMA, CIC, COC, CDI.
• Extensive coding and auditing background.
• Extensive knowledge of the internal claims payment system.
• Knowledge of coding, audit and RADV methodologies and their application to healthcare and the development of written summaries, processes, or guidelines.
• Expert knowledge of coding and documentation requirements including ICD-10-CM, CPT and HCPCS and coding guidelines.
• Expert knowledge of medical terminology, anatomy and physiology, pharmacology, and pathology required.
• Expert knowledge of payment models related to risk adjustment, including but not limited to CMS HCC (Hierarchical Condition Categories) Risk Adjustment, ACA, and Medicare RADV protocols.
• Excellent verbal and written communication skills, analytical skills and organization skills required.
• Extensive problem-solving experience is required.
• Expert competence in analysis and problem solving, documentation and communication.
• Extensive professional presentation experience and the ability to present information in a clear and professional manner required.
• Extensive experience participating in government RADV and HCC audits.
• Goal-oriented and experienced with development and implementation of strategic action plans.
• Expert computer skills in MS Office and Power Point required.
• Expert in researching internal health record systems (Excel, Access, Word, Document Viewer, EPIC, McKesson, and HCC Coding Software).