Job Summary
The Senior Risk Adjustment Specialist reviews medical records to ensure all ICD-10-CM codes are accurate and compliant with supportive documentation for submission to the Centers for Medicare and Medicaid Services (CMS). This role is a resource for the Risk Adjustment Specialists and provides subject matter expertise.
Why VIVA HEALTH?
VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.
VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nations Best Places to Work by Modern Healthcare.
Benefits
- Comprehensive Health, Vision, and Dental Coverage
- 401(k) Savings Plan with company match and immediate vesting
- Paid Time Off (PTO)
- 9 Paid Holidays annually plus a Floating Holiday to use as you choose
- Tuition Assistance
- Flexible Spending Accounts
- Healthcare Reimbursement Account
- Paid Parental Leave
- Community Service Time Off
- Life Insurance and Disability Coverage
- Employee Wellness Program
- Training and Development Programs to develop new skills and reach career goals
- Employee Assistance Program
See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits
Key Responsibilities
- Maintain thorough understanding of the risk-adjusted payment methodology; what can be submitted by the plan and how/when submission impacts CMS payments.
- Demonstrate knowledge of ICD10 coding guidelines, medical terminology, disease processes, and pharmacology.
- Interpret and demonstrate analytical and problem-solving ability to accurately assign ICD10 codes that are clinically identified and supported in the medical record.
- Work with department management to communicate provider coding accuracy concerns and challenges.
- Ability to identify HCC improvement opportunities and educate clinical providers on proper clinical documentation, compliance, and coding guidelines.
- Report findings of chart audits and Clinical Documentation Improvement (CDI) opportunities to providers to maximize the coding of ongoing risk adjusted conditions.
- Query providers when necessary to obtain clarification for unclear documentation.
- Collaborate with providers regarding coding changes, questions concerning documentation, diagnosis coding, and level of service.
- Conduct chart reviews to identify clinically supported diagnoses based on CMS-HCCs and specific HEDIS measures.
- Support any ongoing program that minimizes any organizational risk in the event of a Risk Adjustment Data Validation (RADV) audit.
- Communicate with Department Management to keep abreast of potential risk exposure related to coding and/or documentation practices by providers and/or coding personnel.
- Provide support and compliance through effective communication and training/education.
- Train and mentor new Risk Adjustment Specialists.
- Assist management with workflow improvements and process optimization.
- Serve as an escalation point for complex coding questions and issues.
- Monitor provider coding performance and trends.
- Evaluate coding practices for regulatory and compliance risk.
- Support RADV audits, validations, and related projects.
REQUIRED QUALIFICATIONS:
- High School Diploma or GED
- At least 5-7 years experience with coding
- Certified Coder (AHIMA or AAPC credentials)
- Read and interpret handwritten and typewritten medical documentation
- Ability to work under pressure to meet deadlines with minimal supervision
- Basic computer skills
- Ability to maintain flexible work schedule to meet department needs required
- Demonstrate excellent customer service sills through written and verbal communication
- Demonstrate leadership among coding team
PREFERRED QUALIFICATIONS:
- 2 or more years of college
- Experience with hospital coding