Job Title: HCC Auditor/Coder
Reports To: Sr. ACI Manager
FLSA Status: Exempt
The HCC Auditor/Coder
will review medical records for accurate code selection, to include highest
level of specificity, documentation validation, compliance with ICD-10 coding
guidelines, and quality of care opportunities.
- Reviews outpatient medical records on both a
retrospective and prospective basis to ensure
documentation accurately reflects and supports code selection based on the
ICD-10 coding guidelines, which are submitted to CMS for reimbursement
based on the CMS Hierarchical Condition Categories (HCC) conditions that
are applicable to Medicare Risk Adjustment reimbursement initiatives.
- Performs physician queries as
needed in order to validate ICD-10 diagnosis codes and follows established
physician query policy and procedure.
- Ensures the diagnosis codes for each chronic or
major medical condition have been captured and submitted within the
permitted CMS timeframe.
- Safeguards medical records and preserves the
confidentiality of personal health information.
- Keeps current on changes in
coding and reimbursement requirements for government programs and other
third party payers.
- Ensures compliance with all
applicable Federal and State laws and regulations related to coding and
documentation guidelines for Risk Adjustment.
Knowledge, Skills & Abilities
· Risk Adjustment
methodology experience preferred
· Proficient knowledge
of CMS-HCC Model and guidelines
· Ability to interpret,
analyze and abstract data/documentation
· Ability to identify
HCC improvement opportunities and provide feedback to physicians on proper
clinical documentation, compliance, and coding guidelines
· Excellent organization
and problem-solving skills required.
· Strong oral and
written communication skills required.
· Strong time management
· Ability to work in a
continuously changing environment.
· Must possess a high
degree of accuracy, efficiency and dependability.
· Ability to work
effectively as a team member.
Experience & Education
- Must have a minimum of 3 years coding
experience with at least 1 year HCC Risk Adjustment experience and
successful completion of a coding certificate program from one of the
following is required: Certified
Professional Coder (CPC); or Certified Coding Specialist - Physician
- High School diploma or equivalent required.
Bachelor’s degree in related field preferred; and/or relevant equivalent
and relevant work experience preferred.
working under stressful conditions where constructive criticism from others is
encouraged. Requires working extended or irregular hours (including evenings
and occasional weekends) as the medical group determines necessary or desirable
to meet its business needs and/or the needs of its patients. Requires prolonged
sitting, some bending, stooping and stretching and occasional lifting up to 50
pounds. Requires eye-hand coordination
and manual dexterity sufficient to operate a keyboard, photocopier, telephone,
calculator and other office equipment. Requires normal range of hearing and eyesight
to record, prepare and communicate appropriate reports. Normal office environment.