Adjustment Clerk jobs in Syracuse, NY

Summary:

The Risk Adjustment Coding Provider Education Consultant is responsible for applying clinical and medical coding knowledge in the review of documentation in medical records and submission of diagnoses on claims as it relates to Risk Adjustment (RA). This position requires the ability to perform accurate and complete diagnostic coding using American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) and Centers for Medicare & Medicaid Services (CMS) guidelines for Risk Adjustment.

This position serves as a consultant and subject matter expert in all aspects of coding and medical record documentation requirements as they apply to Risk Adjustment. The RA Coding Provider Education Consultant reviews medical record coding and documentation, and provides education, oversight, guidance and training to partner practitioners and non-clinical staff related to Risk Adjustment, CMS guidelines and HCC best practices. This position prepares and presents outcome reports on program activities and performance to internal and external stakeholders and also follows up on corrective action plans as required.

Essential Primary Responsibilities/Accountabilities:

Level I

• Applies CMS Risk Adjustment coding guidelines and AAPC or AHIMA coding certification to review medical records after encounter and provide feedback to physician and/or physician group for the purposes of improving risk adjustment documentation and complete and accurate claim submission.
• Applies understanding of physician/facility practices and supports practice transformation through education and support to participating groups to improve documentation and ICD code submission.
• Analyzes, reports, and presents overall impact of initiated programs. Based on in-depth analysis, determines degree of replicability and ROI. Leads creation of reports and makes strategic recommendations on findings to leadership to guide decision making and strategy planning.
• Provides various methods of providing feedback and education to physician practice and office staff with ICD-10-CM coding focusing on Medicare Risk Adjustment documentation and coding opportunities.
• Assists in the collection and analysis of qualitative and quantitative data as it relates to risk adjustment specifically around missed opportunities, prevalence and suspects.
• Demonstrates analytical and problem-solving ability regarding barriers to improve accuracy of HCC coding.
• Assists in the design and development of ad hoc reports and presentations for risk adjustment initiatives.
• Performs outreach on risk adjustment education based on review of pre-selected charts coupled with data management, data reporting and analysis, and Practitioner scorecards.
• Reviews physician profiles, creates training resources based on coding trends and documentation gaps across physicians.
• Continually monitors and assesses the effectiveness of the program, timeliness, physician progress and report to leadership when appropriate. Identifies opportunities to improve accuracy and completeness for revenue impact.
• Meets with organizational leadership to partner on physician Risk Education Strategy.
• Assists with the development of physician and staff coding remediation plans where appropriate including Practitioner assessment and scorecard.
• Meets Risk Adjustment Program Operations productivity metrics and coding accuracy scores (participates in Inter-rater reliability projects).
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II – In addition to responsibilities of Level I

• Collaborates with Finance Risk Adjustment, Network Contracting, Medical Directors, Regional Presidents, and Practitioner Relations to identify program needs and ensure alignment and support with Organizational strategies, including financial, contracting and network management strategies.
• Performs and/or collaborates with internal business stakeholders on analysis of trend issues, cost savings opportunities, utilization patterns, and other analysis as needed for Risk Adjustment
• Coordinates special projects and develops reports for Finance Division.
• Represents the Health Plan and collaborates with key community CMOs, CEOs, COOs and other stakeholders on community-wide Risk Adjustment improvement
• Identifies and engages key target hospitals and physicians/practices in risk adjustment improvement programs.
• Provides consultation, complex performance analysis, and coaching expertise to hospital/physician practice leadership around strategies and methods of continuous risk adjustment improvement.
• Fosters a culture of continuous improvement that includes the use of performance data to understand health care cost, risk adjustment scores and trends, clinical and condition management documentation, and chronic condition suspecting.
• Anticipates Practitioner coding and documentation improvement needs; informing management of Practitioner performance industry patterns as a result of working with practitioner practices and groups.

Minimum Qualifications:

NOTE: This description includes multiple levels of classification. The levels of classifications are differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making and in some cases, becoming a resource to others. New hires will be placed in the level for which they are most qualified based on their experience, credentials and skills.

Level I

• 3 years of related work experience required.
• Associate’s Degree in nursing or health related field preferred.
• RN or equivalent clinical education and background, preferred.
• CPC or CRC coding certifications required. Other current coding certification (CPC-H, CPC-I, CCS, RHIA, RHIT, etc.) through AHIMA or AAPC preferred.
• Working knowledge of CMS Risk Adjustment and HCC Coding Process, preferably in Health Insurance environment, medical office environment, or managed care environment.
• Knowledge of Medicare guidelines, rules and regulations.
• Thorough detailed understanding of the healthcare delivery system and understanding of Medicare Advantage Risk Adjustment and Risk contracting.
• Strong experience in health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products (e.g. ICD- 10, CPT, HCPC).
• Ability to verify accuracy of data to report information correctly.
• Possesses good listening skills; builds strong relationships; is flexible/open-minded; solicits feedback and handles constructive criticism.
• Self-motivated with excellent follow through skills with ability to work independently with minimal to moderate supervision and demonstrated ability to work as an effective team member.
• Ability to communicate and interact positively and professionally throughout all levels of the organization and with external customers.
• Excellent writing and both oral and visual presentation skills.
• Demonstrates a bias for action and strong organizational skills.
• Must possess strong, persuasive and effective communication, people and project management skills.
• Knowledge of educational theories, methods and strategies as well as adult learner training/facilitating experience.
• Ability to provide proactive and creative solutions to business problems.
• Must possess project management skills, investigative skills, analytical, problem solving and research competence.
• Understanding of the functionality and use of risk adjustment software products.
• Excellent PC skills including Excel, Word, PowerPoint, Access and Lotus Notes.

Level II – in addition to qualifications in level I:

• Bachelor’s Degree preferred.
• 5 years of related work experience required.
• 3 years of Risk Adjustment (HCC) coding experience.
• Current Certified Risk Adjustment Coder (CRC).
• Seasoned, polished professional who is capable of handling higher profile Practitioners and executing key organizational strategies.
• Provides insight to practitioner offices on implementing program into practice processes.
• Knowledge and competency in change agent theory. Demonstrated successful coaching skills.
• Recognized as a subject matter expert.
• Strong project management skills. Ability to manage multiple high profile/impact projects/Practitioners concurrently with demonstrated outcomes. Exhibits strong organizational and planning skills.
• Ability to define or identify problems and prioritizes impact or corrective action/implementation to drive execution.
• Experience developing training programs and Practitioner tools.
• Experience developing risk adjustment/documentation programs for medical Practitioners
• Previous experience educating Practitioners preferred.

Physical Requirements:

• Must have ability to travel.

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Job Type: Full-time

Pay: $60,000.00 - $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Parental leave
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• Hybrid work

Ability to Relocate:

• Syracuse, NY 13214: Relocate before starting work (Required)

Work Location: Hybrid remote in Syracuse, NY 13214