Performs chart retrieval, medical record review, HCC identification and data quality oversite 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. Helps in the preparation with all Risk Adjustment Data Validations (RADV) audits as well as serving as the CMS liaison for coding questions/issues. Determines adequacy and... more details
Coder, Audit Specialist - Risk Adjustment
SummaCare - 1200 E Market St, Akron, OH
Full-Time / 40 Hours / Days
Remote
SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2024 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Summary:
Performs chart retrieval, medical record review, HCC identification and data quality oversite 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. Helps in the preparation with all Risk Adjustment Data Validations (RADV) audits as well as serving as the CMS liaison for coding questions/issues. Determines adequacy and correctness of physician diagnosis/documentation as it relates to risk adjustment.
Formal Education Required:
a. Associate degree or equivalent combination of education and/or experience.
Experience & Training Required:
a. Five (5) years experience to include leadership experience, medical chart reviews, risk adjustment experience with in-depth working knowledge of CPT coding, ICD 9 and 10 coding, medical terminology, and solid working knowledge of HCC coding.
3. Other Skills, Competencies and Qualifications:
b. Ability to obtain Certified Risk Adjustment Certification (CRC) from American Academy of Professional Coders (AAPC) within 6 months of hire.
c. Demonstrate knowledge of Microsoft Office suite and other software for electronic processing of medical records.
d. Maintains up-to-date knowledge on risk adjustment HCC (Hierarchical Condition Categories) processing concerning ICD 9 and ICD 10 coding guidelines.
e. Maintain current knowledge of medical coding concepts, techniques and principles in regards to risk management activities.
f. Understands medical chart review processes and effectively translate the associated business needs into appropriate solutions and actions.
g. Demonstrate strong attention to detail and understanding the medical record in order to determine the appropriate health conditions (correct diagnosis codes) that should be submitted as additions or redactions for risk adjustment.
h. Organize and manage time to accurately complete tasks within designated periods in fast-paced environment.
i. Maintain current knowledge of, comply with regulatory, and company policies and procedures.
j. Maintain confidentiality of patient and business information.
k. Flexible: ability to adjust work hours to meet business demands.
4. Level of Physical Demands:
a. Sit for prolonged periods.
b. Bend, stoop, and stretch.
c. Lift up to 20 pounds.
d. Manual dexterity to operate computer, phone, and standard office machines.
$25.29/hr - $37.94/hr
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
