Coder, Audit Specialist

Overview

Coder, Audit Specialist - Risk Adjustment at Summa Health. This role is remote.

Summary

Performs chart retrieval, medical record review, HCC identification and data quality oversight for risk mitigation and revenue recovery for both Medicare and ACA services. Assists in the development and management of activities in support of HCC coding while ensuring compliant practices for revenue management and reducing risk. Supports preparation for Risk Adjustment Data Validations (RADV) audits and serves as the CMS liaison for coding questions/issues. Determines adequacy and correctness of physician diagnosis/documentation as it relates to risk adjustment.

Location and Schedule

SummaCare E Market St, Akron, OH

Full-Time / 40 Hours / Days

REMOTE

Responsibilities

• Oversee the chart review lifecycle from scheduling access, collecting images, coding chart data, developing the supplemental record, and submission of the RAPS file to CMS.
• Determine adequacy and correctness of medical documentation as it relates to risk; proactively identify and implement opportunities for improvement.
• Serve as a resource regarding quality coding per guidelines and supervise the quality of internal and external coders.
• Develop policies, procedures, operational workflows, auditing worksheets, and other documentation to support department processes concerning risk adjustment, risk mitigation, and RADV activities.
• Oversee periodic audits of revenue realization activities; implement quality oversight on the retrospective chart review process, home visits, and bidirectional reviews; report findings and develop corrective action plans.
• Act as the primary liaison with the provider community and the official representative to Health Plan Alliance Coding workshops.
• Educate and provide feedback to provider offices about medical record documentation and coding issues to facilitate accurate claims submissions and reduce RADV risk exposure.
• Ensure all Level 1 coders maintain updated knowledge of coding requirements through continuing education and certification renewal.
• Prepare educational materials on coding requirements and conduct training to ensure accuracy of the medical records review process.
• Coordinate user group meetings, conference calls, and training sessions and ensure attendance documentation is supplied to Compliance.
• Assist in defining chart chase logic parameters and in developing internal/external risk adjustment tools related to revenue enhancement or risk mitigation.
• Perform all job functions with integrity and provide timely internal and external customer service in a cooperative, professional, and respectful manner.

Qualifications

• Associate degree or equivalent combination of education and/or experience.
• Five (5) years of experience including leadership, medical chart reviews, risk adjustment experience with in-depth knowledge of CPT coding, ICD-9/10, medical terminology, and solid understanding of HCC coding.

Other Skills, Competencies and Qualifications

• Ability to obtain Certified Risk Adjustment Certification (CRC) from the American Academy of Professional Coders (AAPC) within 6 months of hire.
• Demonstrated knowledge of Microsoft Office and software for electronic processing of medical records.
• Up-to-date knowledge on risk adjustment HCC processing concerning ICD-9/10 coding guidelines.
• Current knowledge of medical coding concepts, techniques, and principles in risk management.
• Understanding of medical chart review processes and ability to translate business needs into solutions/actions.
• Strong attention to detail to determine appropriate health conditions and codes for RADV submissions.
• Ability to organize and manage time effectively in a fast-paced environment.
• Maintain current knowledge of regulatory and company policies and procedures; maintain confidentiality of patient and business information.
• Flexibility to adjust work hours to meet business demands.

Level of Physical Demands

• Sit for prolonged periods; bend, stoop, and stretch.
• Lift up to 20 pounds.
• Manual dexterity to operate computer, phone, and standard office equipment.

Salary and Benefits

$25.54/hr - $38.32/hr. This base salary range excludes bonuses or differentials. Hiring at the maximum of the range would not be typical. Many factors, such as years of relevant experience and geographical location, are considered when determining starting pay. Summa Health offers a competitive benefits program including medical, dental, vision, life, paid time off, and other benefits.

• Basic Life and AD&D
• Supplemental Life and AD&D
• Dependent Life Insurance
• Short-Term and Long-Term Disability
• Additional insurance options (e.g., Accident, Hospital Indemnity, Critical Illness)
• Retirement Savings Plan
• Flexible Spending Accounts – Healthcare and Dependent Care
• Employee Assistance Program (EAP)
• Identity Theft Protection
• Pet Insurance
• Education Assistance
• Daily Pay

Equal Opportunity

Equal Opportunity Employer/Veterans/Disabled

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