Risk Adjustment Field Reviewer/Coder HCCs FL Blue

Bradenton, Florida
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Risk Adjustment Field Review Spec-7063


Job Summary: Performs Retrospective and Prospective chart reviews under direction of the Regional Risk Adjustment Educator. Identifies trends and educational opportunities regarding both administrative and coding/documentation processes. Provides Regional Risk Adjustment Educator with findings for use in determining future educational and engagement strategies.

Essential Job Functions:

•HCC Risk Adjustment Retrospective and Prospective Chart Reviews emphasizing correct coding to the highest level of specificity and impact of diagnosis code selection on the Risk Adjustment assignment to ensure proper level of reimbursement
•Auditing of medical records on a concurrent and retrospective basis to ensure compliance with applicable coding and documentation standards with an emphasis on diagnosis codes mapping to HCCs
•Conduct HCC-focused reviews on providers including tracking results and identifying trends and deficiencies for follow up training; report to the health plan regarding results to assist the plan in targeting deficient providers
•Year-to-date, month-to-date, and real-time report generation to identify low score providers and providers whose HCC reporting is low in comparison to panel size
•Effectively communicate the audit process and results to the appropriate department and management and serves as liaison between provider group and health plan
•Maintains current knowledge of ICD-10 code and CMS documentation requirements and maintains a clear understanding of regulatory compliance
•Support and participate in process and quality improvement initiatives.
•Understands strategic direction of business unit and the organization
•Recognizes problems and responds; systematically gathers information; sorts through complex issues; seeks input from others; addresses root causes of issues; uses consensus when possible; communicates decisions to others
•Applies understanding of physician/facility practices and supports practice transformation; translates business needs into practical applications and innovative solutions for practices
•Perform other duties as assigned
Minimum Job Requirements:
•Bachelor’s Degree or equivalent work experience
•3+ years’ related work experience
•Experience with retrospective and/or prospective chart review including providing coding and documentation improvement education at administrative and physician levels
•Certified Professional Coder (Medical Record)
•Experience working with CMS and HHS guidelines, rules and regulations
•Thorough detailed understanding of the healthcare delivery system and understanding of Medicare Advantage Risk Adjustment, Risk contracting and medical terminology
•Communicates well verbally and in writing; creates accurate and punctual reports; delivers presentations; shares information and ideas with others
•Periodic overnight travel within the state of Florida
•Proficiency in MS Word, PowerPoint, Excel
Preferred Criteria:
•Certified Risk Adjustment Coder (CRC)
•Thorough detailed understanding of the healthcare delivery system (various functional areas within a physician office setting)
•Experience with BCBSF product knowledge, knowledge of over 65 product
•Experience with understanding of industry knowledge regarding health care reform and associated CMS/HHS compliance standards
•Experience with alternative payment systems and Medicare Risk Adjustment structures


Primary Location United States-Florida-Tampa

Organization Blue Cross Blue Shield of Fla

Schedule Full-time

Posting Deadline Ongoing