Job Title: Risk Coding (HCC) Specialist

Department/Location : Marlton, NJ/Hybrid [Remote within USA, Marlton, NJ]

Reports to: Vice President, VBC Operations

FLSA Status: Non-Exempt

Direct Reports: None

Position Summary

Performs audits and monitoring of clinical documentation analyzing medical records and assessing the accuracy of ICD-10-CM/PCS, E&M, HCC, CPT or HCPCS codes; determines compliance with appropriate policies, procedures, and regulations. Identifies and recommends strategies for process improvement. Prepares written reports on findings. Maintains up-to-date working knowledge on regulatory requirements associated with outpatient and procedure area coding and billing and claims processing. The Risk Coding Specialist will participate in all aspects of the organization’s Compliance Program.

Duties and Responsibilities

The duties include, but are not limited to:

• Perform internal audits, including the execution of strategic, operational, and compliance risk-based audits for evaluating controls and processes for scalability, effectiveness, efficiency, and risk mitigation strategies.
• Conduct medical record documentation and coding/billing audits, assessing the accuracy of ICD-10-CM/PCS, CPT, HCPCS codes, modifier assignments, etc., determining compliance with appropriate policies, procedures, Payor requirements and Federal and state regulations.
• Researches, analyzes, and responds to inquiries regarding compliance, inappropriate coding, denials, and billable services.
• Assists with creating audit tools to be used to perform the applicable audits of the various types of Providers.
• Prepare comprehensive reports, making recommendations to correct deficiencies and practice or process improvements.
• Interacts with physicians and other patient care providers regarding billing and documentation policies, procedures, and regulations; obtains clarification of conflicting, ambiguous, or non-specific documentation.
• Interacts with providers and management to review and/or implement codes and to update charge documents.
• Serve as contact for Payor external auditors.
• Generates reports as needed through various systems.
• Assists in provider education.
• Performs miscellaneous job-related duties as assigned.

Qualifications or Education, Training and Experience

• 2+ years’ experience in the healthcare field.
• High School diploma or GED required, Bachelor’s degree preferred.
• Must have certification through recognized national coding accreditation agency such as American Health Information Management Association or the American Academy Professional Coders: Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P), Certified Professional Medical Coder (CPC), or Professional Medical Coder Outpatient Hospital (COC), CPMA (Certified Professional Medical Auditor).
• Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis (doesn’t replace the necessary AAPC or AHIMA coding certification required).
• Must obtain Certified Risk Adjustment Coder (CRC) certification within 6 months of hire.

Knowledge and Skills/Expected Competencies

• Proficient in Microsoft Office Suite software and Windows 10.
• Knowledge of auditing concepts and principles.
• Advanced knowledge of medical coding and billing systems and regulatory requirements.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems.
• Strong communication and interpersonal skills.
• Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures and documentation.
• Knowledge of current and developing issues and trends in medical coding procedures requirements.
• Ability to clearly communicate medical information to professional practitioners and/or the public.
• Detailed knowledge of medical coding systems, procedures, and documentation requirements.
• Ability to adapt and modify medical billing procedures, protocol, and data management systems to meet specific operating requirements.
• Ability to provide guidance and training to professional and technical staff in area of expertise.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Work from home

Schedule:

• Day shift
• Monday to Friday

Experience:

• HCC: 1 year (Preferred)

Work Location: Remote

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