General Summary: This role focuses on the Risk Adjustment process that supports the documentation of acuity diagnoses for the Managed Care (MC) patient population and required activities for submission of records to Medicare Advantage (MA) payers under established capitated contracts. It assists with medical record reviews for HCC diagnoses, correct usage of various coding guidelines (ICD-10-CM, CPT, HCPCS) and federal and MA payor regulations, as well as clinical validation of appropriate supporting documentation.
Supervisory Responsibilities: This position has no supervisory responsibilities.
General Requirements: All duties performed will be done accurately and in a timely manner.
- Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
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Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
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Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
- Participates in other Managed care projects to include but not limited to marketing events, and Medicare Open enrollment period.
- Reviews reports to identify areas for improvement or needed action to meet departmental goals.
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Supports team members in all aspects of the Risk Adjustment process to ensure that defined timelines and departmental goals are met.
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Adhere to all confidentiality and HIPAA requirements as always outlined within Gonzaba Medical Group Operating Policies and Procedures in all ways and with respect to any aspect of the data handled or services rendered.
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Other duties as assigned.
Essential Job Responsibilities:
- Maintain compliance with Gonzaba Medical Group policies, Official Coding Guidelines and the Gonzaba Medical Group Coder’s Pledge.
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Provides queries or technical guidance to physicians, clinical staff, and other departmental staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines data in the form of a query, email and or task.
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Accurately validate and abstract diagnosis codes from provider documentation in the patient medical record to ensure that reported ICD-10 codes are appropriately supported by the documentation.
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Selects correct ICD-10-CM (diagnostic), CPT (procedural) and HCPCS codes based upon interpretation of office visit and other documentation, correct coding principles, and clinical validation with a focus on accurate capture of all supported HCC diagnosis codes. Remains up to date on all coding changes and usage.
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Assesses qualifying notes for completion and/or identification of deficiencies; Communicates with provider/staff on elements to be addressed to ensure the note can be processed within the required timeline.
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Performs review of Risk Adjustment audits for accuracy and for data entry into the EMR.
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Utilizes nursing and coding knowledge to assist with review activities to support the Risk Adjustment process to include re-review of audit findings to ensure accuracy in documented HCC diagnoses and ICD-10 coding; review of various payer denial/rejection reports to identify areas for provider education.
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Completes required electronic forms necessary for submission of applicable acuity diagnosis codes based on scheduled appointments.
Education and Training: Minimum high school education or equivalent required. An active Coding Certification by AHIMA (RHIA, RHIT, CCS, CCS-P or CCA) or AAPC (CPC, CRC) is required. Graduation from an approved practical nursing program and state-licensed practical nurse preferred. CPR with AED certification required. All certifications are required as initial and continued employment at Gonzaba Medical Group.
Experience: 3+ years’ experience in working with the Risk Adjustment (HCC) process preferred. Knowledge of ICD-10-CM, CPT, and HCPCS coding systems, guidelines, and rules. Knowledge of billing regulations, Managed Care insurance coverage limitations and protocols. Knowledge of medical terminology, medical procedures, human anatomy, and physiology.
Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.
Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.
Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.
