Risk Adjustment Coding & Documentation Specialist

Company: Sentara Health
Location: Miami
Posted on: January 30, 2025

Job Description:

City/State
Doral, FL

Overview

Work Shift
First (Days) (United States of America)

AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Risk Adjustment & Documentation Specialist in Miami, FL. This is a hybrid position, 2 days in office and 3 days remote.

Scope of the Position:
Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS). Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC). Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities. Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight. Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding. Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns. Serves as subject matter expert on risk adjustment diagnosis coding guidelines. Coordinates risk adjustment gap elimination with clinical and quality gap elimination Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.

Requirements:

Associate degree required in healthcare administration, nursing, health information management, accounting, finance, or other related field with 2 years of medical coding experience. In lieu of Associates degree, 4 years of medical coding experience required. Must have thorough knowledge and understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics. One-year previous experience with paper and/or electronic medical records required.

One of the following certifications are required: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).

Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment. Prefer one-year experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital). Prefer previous experience with CMS, HHS and/or CDPS+RX Hierarchical Condition Categories (HCC) models. Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.

Our Benefits:

As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:

--- Medical, Dental, and Vision Insurance
--- Paid Annual Leave, Sick Leave
--- Flexible Spending Accounts
--- Retirement funds with matching contribution
--- Supplemental insurance policies, including legal, Life Insurance and AD&D among others
--- Work Perks program including discounted movie and theme park tickets among other great deals
--- Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We are setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)

Join our team! We are committed to quality healthcare, improving health every day, and providing the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if the established system and employee eligibility criteria are met.

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Job Summary

Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS). Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC). Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities. Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight. Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding. Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns. Serves as subject matter expert on risk adjustment diagnosis coding guidelines. Coordinates risk adjustment gap elimination with clinical and quality gap elimination Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.

Associate degree required in healthcare administration, nursing, health information management, accounting, finance, or other related field with 2 years of medical coding experience. In lieu of Associates degree, 4 years of medical coding experience required. Must have thorough knowledge and understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics. One-year previous experience with paper and/or electronic medical records required.

One of the following certifications are required: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).

Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment. Prefer one-year experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital). Prefer previous experience with CMS, HHS and/or CDPS+RX Hierarchical Condition Categories (HCC) models. Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.

Qualifications:

ALD - Associate's Level Degree

Certified Professional Coder (CPC) - Certification - American Academy of Professional Coders (AAPC)

Coding, Medical Records Data

Skills

Active Learning, Active Listening, Communication, Coordination, Critical Thinking, Judgment and Decision Making, Leadership, Mathematics, Microsoft Excel, Microsoft Word, Monitoring, Reading Comprehension, Service Orientation, Social Perceptiveness, Speaking, Technology/Computer, Time Management, Troubleshooting, Writing

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment. Associated topics: actuarial, actuarial consultant, actuarial director, actuary consultant, analyst, assistant actuary, associate actuary, investment actuary, life actuary, model

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