Senior Hierarchical Condition Category (HCC) Coding Specialist

Company :
Highmark Inc. Job Description :
JOB SUMMARY

This job will deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding. Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums. May also complete analysis on provider coding trends, create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis.
ESSENTIAL RESPONSIBILITIES

- Conducts data analyses from medical record reviews; proactively summarizes opportunities to enhance provider documentation to improve coding accuracy and thorough capture of members’ chronic health conditions. Conducts quality reviews of high-risk and incremental HCCs and applies expertise to analyze documentation and mitigate risk to the organization. Collaborates with team members to optimize data collection and review, provider education and outreach, and coding quality.20%

- Develops and presents process improvement and training initiatives to improve efficiency and accuracy of departmental coding practices.Regularly presents and contributes to coding education meetings and Annual Coding Summit.Adapts presentation style to audience; provides constructive feedback; presents in-person, virtually and/or by webinar. Completes analytics on providers and/or provider group coding trends and creates and delivers externally facing presentations to provider documentation and accuracy, acts as the point person for the provider office for any questions and additional trainings, as needed.20%

- Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures to guide HCC coding decision making. Achieves and maintains coding productivity and quality accuracy metrics set by the management team.20%

- Contributes to Risk Adjustment Data Validation (RADV) audit coding review, including analysis of claims data to ensure chart acquisition is complete and documentation is comprehensive; applies CMS coding guidelines to validate audited condition(s); assists with review and ranking of charts for submission.10%

- Executes assigned projects in accordance with project plans; monitors progress and makes adjustment as necessary to ensure successful completion. Participate on ad-hoc projects per the direction of leadership to address the needs of the department.10%

- Mentors new hires and coworkers on CMS and Highmark coding guidelines and contributes to onboarding and training material development and enhancement.10%

- May support external vendor quality review(s) to measure coding accuracy, prepare and report findings, and monitor accuracy.10%