Quality, Education & Coding Specialist

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work.
• Reduce health disparities.
• Become an anti-racist organization.
• Create an equitable work environment.

About the Role

Quality, Education & Coding Specialist works collaboratively with clinic and providers for enhancements, training and education for risk adjustment documentation and performs medical record reviews in accordance with HEDIS technical specifications. This position requires demonstrated knowledge, skill and ability to educate, train and advise clinical staff for process improvements.

This position is also responsible for performing quality medical record reviews, assisting providers and staff in the improvement of clinical documentation and workflows, identifying trends and gaps in care, maintaining accurate records of review activities, ensures all data submitted to the health plan meets HEDIS technical specifications for medical records.

To be successful in this role, you:

• Possess an Associate’s Degree or an equivalent combination of education and highly relevant experience required.
• Have current Coding Certification (CPC, CPC-P, CPC-H, CPC-I, CRC, CCS, RHIT, RHIA etc.) through AAPC and/or AHIMA required.
• Have current, unrestricted license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) required.
• Possess a minimum of three years coding experience with specific knowledge of Medicare and Commercial Risk Adjustment such as Hierarchical Condition category (HCC) and/or Chronic Illness and Disability Payment System (CDPS).
• And a minimum of three years working with HEDIS data including chart review/collection. HEDIS, QRS, or STARs experience.
• Have experience in Health Plan Risk Adjustment Data Validation Audit (RADV) experience is preferred.
• Have clinical knowledge related to chronic illness diagnosis, treatment and management.
• Have experience working with clinical staff for process improvement; ability to provide education and coaching to clinic staff.
• Have experience with Microsoft Office applications, including Word, Excel and PowerPoint.

Essential functions and Roles and Responsibilities:

• Collaborate, educate and train clinical support staff and providers on risk adjustment documentation and workflows specific to HCC and CDPS models.
• Ensure compliance with internal coding guidelines, department policies, and CMS risk adjustment coding guidelines, rules and regulations. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting.
• Audit provider and vendor documentation of ICD-10 codes to ensure adherence with risk adjustment guidelines.
• Perform root cause analysis to identify issues that may contribute to coding, documentation, claims or other revenue cycle deficiencies.
• Provide coding support, education and training related to, quality of documentation, level of service and diagnosis coding consistent with established coding guidelines and standards to providers and staff.
• Provide real-time support for clinical care and HEDIS/Star teams for annual submission.
• Maintaining an abstraction proficiency rate of 95% by correctly reading, interpreting, and abstracting various components of the medical record such as notes, consultations, medication forms, treatment plans, health history, interval history, and past history.
• Maintaining productivity level of a minimum of 50 chases/charts per defined period according to policy.
• Utilizing various software applications to support department operations and accurately entering the results of chart audits into the database.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Applied understanding of principles of reimbursement based on risk adjustment model(s) including CMS Hierarchical Condition Categories (HCCs) and Chronic Illness and Disability Payment System (CDPS).
• Knowledge of acceptable medical record standards and criteria in the context of risk adjustment data validation (RADV).
• Advanced, applied knowledge of ICD-CM codes, coding conventions and coding guidelines.
• Proficiency with computer business applications, and a working knowledge of electronic medical record (EMR) software.
• Demonstrated ability to educate, coach and advise clinical staff for process improvement and workflow re-design.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Demonstrated organizational, time management, and project management skills.
• Strong written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers.
• Willingness to be part of a fast moving, and dynamic clinical development team.
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.
• Meet attendance and punctuality standards.
• Strong computer skills and reliable high-speed internet access at home.
• Demonstrate professional courtesy to others and ability to maintain confidentiality.
• Ability to be proactive in problem identification and resolution.
• Ability to work independently.

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime and has a 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental:

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.