Medicare Risk Adjustment Program Specialist Jobs

Bham-Corporate Office
Birmingham, AL 35203, USA

Job Summary

The Senior Risk Adjustment Specialist reviews medical records to ensure all ICD-10-CM codes are accurate and compliant with supportive documentation for submission to the Centers for Medicare and Medicaid Services (CMS). This role is a resource for the Risk Adjustment Specialists and provides subject matter expertise.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Maintain thorough understanding of the risk-adjusted payment methodology; what can be submitted by the plan and how/when submission impacts CMS payments.
• Demonstrate knowledge of ICD10 coding guidelines, medical terminology, disease processes, and pharmacology.
• Interpret and demonstrate analytical and problem-solving ability to accurately assign ICD10 codes that are clinically identified and supported in the medical record.
• Work with department management to communicate provider coding accuracy concerns and challenges.
• Ability to identify HCC improvement opportunities and educate clinical providers on proper clinical documentation, compliance, and coding guidelines.
• Report findings of chart audits and Clinical Documentation Improvement (CDI) opportunities to providers to maximize the coding of ongoing risk adjusted conditions.
• Query providers when necessary to obtain clarification for unclear documentation.
• Collaborate with providers regarding coding changes, questions concerning documentation, diagnosis coding, and level of service.
• Conduct chart reviews to identify clinically supported diagnoses based on CMS-HCCs and specific HEDIS measures.
• Support any ongoing program that minimizes any organizational risk in the event of a Risk Adjustment Data Validation (RADV) audit.
• Communicate with Department Management to keep abreast of potential risk exposure related to coding and/or documentation practices by providers and/or coding personnel.
• Provide support and compliance through effective communication and training/education.
• Train and mentor new Risk Adjustment Specialists.
• Assist management with workflow improvements and process optimization.
• Serve as an escalation point for complex coding questions and issues.
• Monitor provider coding performance and trends.
• Evaluate coding practices for regulatory and compliance risk.
• Support RADV audits, validations, and related projects.

REQUIRED QUALIFICATIONS:

• High School Diploma or GED
• At least 5-7 years' experience with coding
• Certified Coder (AHIMA or AAPC credentials)
• Read and interpret handwritten and typewritten medical documentation
• Ability to work under pressure to meet deadlines with minimal supervision
• Basic computer skills
• Ability to maintain flexible work schedule to meet department needs required
• Demonstrate excellent customer service sills through written and verbal communication
• Demonstrate leadership among coding team

PREFERRED QUALIFICATIONS:

• 2 or more years of college
• Experience with hospital coding

Equal Opportunity Employer
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