Medicare Risk Adjustment Educator & Auditor

• Review medical records, including patient medical history, physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, medication lists, health plan reports, and discharge summaries, and interprets such documentation to ensure capture of all MRA relevant diagnoses in coordination with the physician.

• Perform accurate and compliant coding and documentation audits of pertinent medical records and physician services to identify need for coding education to physicians, coders, and other staff involved in the coding and billing process

• Coding reviews include routine and periodic assessment of diagnoses and procedures performed with adherence to established coding guidelines of ICD-10-CM (International Classification of Disease), CPT (Current Procedural Terminology),

• Verifies and ensures the accuracy, completeness, specificity, and proper coding based on CMS HCC categories

• Performs ongoing analysis of medical charts for proper coding and compliance.

• Identifies opportunities for improving individual member risk adjustment score accuracy.

• Ensures compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment Reviews of medical records.
• Provides feedback and training to clinicians and other internal clients on:

• Supporting documentation and physician self-coding that do not meet quality standards.

• Missed coding opportunities.

• Clinical documentation.

• Develops reviews and recommends changes to audit and education documents and templates as needed to enhance the overall auditing and education process.

• Evaluates coding requirements and prepares materials for physicians and their staff prior to coding education instruction sessions in an effective and timely manner.

• Performs miscellaneous compliance audits and company-based audit and education projects as needed or requested by senior Medicare risk adjustment director.

• Participate in audit, education, and coding team meetings to discuss solutions to coding guidance or presentation issues.

• Meets or exceeds required departmental deadlines and goals on a consistent basis.

• Maintains strict confidentiality following HIPAA regulations and Company policy.

• Complies with departmental and company-wide policies and procedures.

• Ability to travel to several sites located in the state of Florida/Texas as needed.

• Minimum 3 years of healthcare experience to include experience in a Managed Care setting.
• Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Risk Adjustment Coder (CRC) required.
• Certified Documentation Expert Outpatient (CDEO).
•  MRA coding experience required. Strong clinical background preferred.
• Proficient of quality improvement standards such as NCQA, HEDIS, CAHPS, HOS and CMS.
• Advanced understanding of medical terminology, body systems/anatomy, physiology, and concepts of diseases processes.
• Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines.

• Excellent listening comprehension, oral communication, and written communication skills and the ability to interact in a positive, tactful, and professional manner.
• Ability to use Microsoft Office.
• Ability to navigate computers, internet programs, and EMR systems
• Ability to multitask and prioritize assignments based on urgency
• Ability to work independently with little or no need for assistance.
• Bilingual English/Spanish-Fluent in English (preferred).

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