Principal Toxicologist – Health Scientist – Risk Assessor
GSI Environmental Inc.
Senior Risk Adjustment Coder – Government Programs
Capital Blue Cross
full-time
Posted on:
Location: Pennsylvania • 🇺🇸 United States
Visit company websiteSalary
💰 $69,720 - $135,340 per year
Job Level
Senior
About the role
- Perform comprehensive review and oversight of medical records for Risk Adjustment compliance following CMS, HHS, and departmental guidelines
- Conduct clinical chart and patient billing audits to identify and validate reported diagnoses for Medicare Advantage and ACO members
- Review medical records and billing history to determine correct billing and documentation of disease conditions
- Adhere to Official ICD-10-CM and CMS risk adjustment guidelines ensuring accuracy, completeness, specificity and appropriateness of diagnosis information
- Leverage other sources (lab results, radiology, comorbid disease states) to find clinical evidence of disease categories
- Perform second-level audits and quality assurance checks on coding by peers or junior coders
- Conduct provider training on coding and documentation best practices
- Assist with production coding when needed and onboard new employees
- Participate in development and maintenance of SOPs, workflows, educational materials, and presentations
- Serve as mentor and lead communication with internal and external stakeholders regarding audit results and education plans
- Contribute to departmental process improvement initiatives and support special projects
Requirements
- 5 years risk adjustment coding experience
- Familiarity with CMS Medicare risk algorithm (CMS-HCC) and ACA risk algorithms (HHSHCC)
- Direct experience speaking with providers required
- Knowledge of RADV audits
- Experience teaching/training others on correct coding guidelines required
- Experience navigating medical records and clinical documentation
- Active Certified Risk Adjustment Coder (CRC) credential required
- Active Certified Professional Coder (CPC), Registered Health Information Technologist (RHIT), or Certified Professional Medical Auditor (CPMA) credential preferred
- Active nursing credential (RN/LPN) preferred
- Proficient with EMR systems e.g., Allscripts, EPIC, AthenaHealth, PracticeFusion, Medent
- Proficiency with Microsoft Word, Excel and PowerPoint or comparable software
- Strong analytical skills and problem solving
- Detail oriented with high degree of accuracy
- Ability to exercise discretion in handling confidential member information
- Strong commitment to customer service and ability to respond within timeframes
- Ability to work independently and manage multiple priorities in a fast-paced environment
- Ability to present in individual and group settings
- Maintains established work production standards and professional growth
