Remote Medicare Risk Adjustment Coding Specialist

You must reside in one of the following states for this position:

AL, AR, AZ, FL, GA, IA, ID, IL, IN, KS, KY, LA MI, MO, MS, NC, NY, OH, OK, PA, SC, TN, TX, UT, WI

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Benefits And Perks Include

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts with company match
• Employee Referral Bonus Program
  
  

Job Summary

The Medicare Risk Adjustment Coding Specialist is responsible for conducting coding audits prior to payment release. Additionally, this position will perform post-payment coding reviews with overpayments and will in turn send coding education correspondence to applicable providers.

Essential Job Duties

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

• Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes based on services rendered.
• Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement
• Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured
• Develop tools and metrics to improve accuracy and completeness of coding and documentation
• Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards
• Escalate appropriate coding audit issues to management as required
• Participate in and support ad-hoc coding audits as needed
• Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit
• Work assigned coding projects to completion
• Other duties as assigned
  
  

Job Requirements

• Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment to include the review of regulatory announcements via educational sessions provided by regulatory entities and educational opportunities within the industry
• Follow all appropriate Federal and state regulatory requirements and guidelines, as well as company policies and procedures
• Maintain established levels of production and quality standards
• Knowledgeable of CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations
• Knowledgeable of coding/auditing claims for Medicare and Medicaid plans
• Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing
• Strong interpersonal skills
• Excellent written and verbal communication skills
• Strong organizational skills; ability to time manage effectively
• Maintain confidentiality
• Strong analytical and critical thinking skills required
• Ability to work remotely without direct supervision
• Successful completion of required training
• Handle multiple priorities effectively
  
  

Required Qualifications

• Education:
• High school or equivalent degree
• Experience:
• 2 years’ experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system
• 2 years’ experience in managed healthcare environment related to claims and/or coding audits
• 2 years’ experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others
• 2 years’ experience with CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations
• 2 years’ experience coding/auditing claims for Medicare and Medicaid plans
• Significant HCC experience (including knowledge of HCC mapping and hierarchy)
• License/Certification:
• Coding certification required (CPC or CRC)
• Travel may be required
  
  

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EQUAL OPPORTUNITY EMPLOYER

This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.

This employer participates in E-Verify.