We enjoy the important work we do every day on behalf of our members.
Job Summary
Under the direction of the Manager, Medical Claims Review & Provider Reimbursement, performs accurate and timely review and validation of Medicare Advantage HCCs through medical record reviews. The Coding Specialist reviews provider documentation of ICD-10-CM codes to verify that coding meets both established coding standards as well as CMS Risk Adjustment guidelines. The Coding Specialist will lead efforts to evaluate the HCC coding practices and provide analyses and recommendations to improve overall provider documentation and coding. The Coding Specialist will review medical records to determine if diagnostic codes (ICD-10-CM) are accurately reflecting the provider documentation. The Coding Specialist will summarize findings for internal and external parties.
Job Description
Performs ongoing audit of medical records from coding vendor and network providers to ensure diagnosis coding accuracy.
Performs medical record audit to determine coding accuracy to coding standards and CMS regulations
Evaluates medical records for appropriate written and electronic signatures as well as other technical requirements.
Summarizes and interprets audit findings for TMP Leadership; tracks audit results over time, identifies trends, and recommends corrective actions.
Collaborates with THP staff and vendors to identify and submit coding adjustments, as needed
Maintains a current and strong understanding of coding rules and CMS guidelines in both inpatient and outpatient settings.
Interprets and summarizes coding guidelines and CMS regulations for THP leadership.
Incorporates changes to guidelines and regulations into audit practice
Researches and resolves coding and risk adjustment regulatory issues
Completion of a formal coding certification program required.
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC-A, CPC, CPC-H, COC, CIC, or CRC) certification or Certified Coding Specialist (CCS-P or CCS) required.
ICD-10 Proficient desired.
EXPERIENCE: (Years of experience)
One to three years of coding experience is preferred.
Knowledge of ICD-10-CM codes and the documentation needed to support them.
Knowledge of medical terminology, ICD-10-CM coding and CMS documentation requirements.
Basic understanding of both the medical and business side of healthcare operations.
Individual must be able to read and understand Medicare guidelines.
Individual must be professional, highly organized, self-motivated, detail-oriented and energetic team player who can also work independently.
Individual must have the ability to multi-task in a fast-paced environment.
Strong computer skills including MS Office particularly Excel and Word, Internet, and E-mail, with the ability to navigate internal network and external internet data portals required.
Knowledge of Microsoft Access and Excel
Intermediate to Advanced level skills preferred.
Strong organization skills and an ability to work autonomously required. Enjoy working in a team environment and participating in the development of departmental quality initiatives.
Individual must possess excellent problem solving ability and strong interpersonal skills and the ability to write clearly and succinctly in a variety of communication settings and styles.
Ability to effectively communicate with multi-level personnel, medical professionals, clients, public and other representatives of the business.
Excellent verbal and written communication skills.
Self starter with ability to learn quickly.
Ability to successfully work on multiple projects/accounts simultaneously with frequent interruptions.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
Individual must maintain a commitment of complete confidentiality of patient health information.
May require limited on site case reviews.
Reliable transportation, car insurance and a valid driver's license required.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
