Quality Assurance Risk Management Jobs in Arizona

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per weekHybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per weekHybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per monthOnsite: daily onsite requirement based on the essential functions of the jobRemote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team buildingPlease note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.PURPOSE OF THE JOBThe Quality Assurance Coder/Auditor will develop a risk mitigation and provider education program. On a regular basis, Coder/Auditor will educate primary care providers and their staff on their historical diagnoses/coding error trends, accurate completion of medical record documentation, and at-risk code identification and risk mitigation, . This includes the review, analysis, and recommended coding based on medical and clinical diagnoses, procedures, injuries, or illnesses contained in medical records and supporting documentation.The Quality Assurance Coder/Auditor will perform risk mitigation analysis using available vendor tools to identify at-risk single occurrence of HCCs and OIG targets. Deletions will be submitted for unsupported/invalid diagnoses. This analysis combined with QA findings and EDPS claims errors will drive the content and audience for provider education.The Quality Assurance Coder/Auditor will perform medical record reviews and abstract codes - to the highest specificity effectively from medical records based on the documentation provided. Coder/Auditor is responsible for ensuring diagnosis codes selected come from a face-to-face visit with a valid Risk Adjustable provider. Coder/Auditor will perform QA for vendors and other submitters of supplemental HCC data and provide educational feedback relevant to same.REQUIRED QUALIFICATIONSRequired Work Experience5 years of professional coding experience, with at least 3 years of HCC coding experience, and 2 years of HCC auditing experience. Advanced knowledge of coding guidelinesRequired EducationHigh School Diploma or GED in general field of studyRequired LicensesN/ARequired CertificationsCertified Coding Specialist – Physician Based (CCS-P), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Outpatient Coding (COC) credentialPREFERRED QUALIFICATIONSPreferred Work Experience5 years of Medicare Advantage health plan experience5 years of experience with HEDIS measures and/or the CMS Star ProgramPreferred EducationN/APreferred LicensesClinical training (Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant)Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (RHIA)Preferred CertificationsCertified Documentation Expert Outpatient (CDEO)Certified Professional Medical Auditor (CPMA)ESSENTIAL JOB FUNCTIOSN AND RESPONSIBILITIESDemonstrate comprehensive understanding of HCC Coding rules, regulations, methodology and the role of hierarchiesReview medical records and supporting documentation, determine completeness and accuracy of medical records and supporting documentation, identify and eliminate barriers to correct coding, and recommend best coding practices and improvementsDetermine valid encounters, including face-to-face, legibility and valid signature, according to Medicare Managed Care requirementsPerform QA audits on vendor and provider group supplemental data submissions. Provide corrective action recommendations when accuracy scores fall below 95%Track QA audits and send out monthly updates to Vendor and management team. Updates include report findings and recommendations regarding closing healthcare gaps, medical record documentation, coding, and additional educational training to management.Develop effective provider/coder education program in support of risk mitigation analysis. This includes writing education tips for BCBSAZ publications and preparing materials for presentation during Zoom callsCorrect encounter rejections within vendor platformMaintain current knowledge of the Medicare Managed Care Manual, Chapter 7 - Risk Adjustment and Medicare outpatient billing systems/processesMaintain coding certification, and stay current with the numerous changes in risk adjustment methodologiesThe position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.Perform all other duties as assigned.REQUIRED COMPETENCIESRequired Job SkillsExcellent understanding of the CMS crosswalk of ICD diagnosis codes to Hierarchical Condition Category (HCC) codes and impact of diagnosis coding on risk adjustment payment modelsSufficient knowledge of anatomy, pathophysiology, and medical terminology necessary to correctly code diagnoses according to CMS and ICD-10 coding guidelinesGeneral knowledge of the provisions contained in Chapter 7 – Risk Adjustment, Medicare Managed Care ManualComputer proficiency in an MS-Windows environment, including MS Word, Excel, and Powerpoint, and ability to learn organizational systems and software applicationsStrong writing skillsComputer proficiency in MS WordAbility to prepare and present PowerPoint slidesAbility to create Excel spreadsheets and perform basic functions in ExcelAbility to learn organizational systems and software applicationsBasic knowledge and understanding of primary care provider office practices, electronic and manual medical record systems, and billing processesRequired Professional CompetenciesAbility to develop training materials and conduct educational training to close healthcare gaps, improve medical record documentation, and ensure complete and accurate codingAbility to identify and effectively communicate medical record documentation and/or correct coding deficiencies to providers and their staffRequired Leadership Experience and CompetenciesN/APREFERRED COMPETENCIESPreferred Job SkillsStrong understanding of the Risk Adjustment Validation Audit (RADV) process for risk adjustment modelsPharmacology knowledgePreferred Professional CompetenciesN/APreferred Leadership Experience and CompetenciesN/AOur CommitmentAZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply. #J-18808-Ljbffr