Risk Adjustment Coding Analyst ERA Sr Job in Eagan, Minnesota

How Is This Role Important to Our Work?

This position is responsible for providing quality assurance and coding audit services for risk adjustment purposes, supporting ACA Commercial, Medicare and Medicaid programs. This includes the gathering, analysis, interpretation and translation of medical and clinical diagnoses, procedures, injuries, or illnesses into designated numerical codes, as well as identifying opportunities for improvement and communicating those opportunities to the appropriate internal teams.

A Day in the Life:

• Performs all administrative duties related to the planning, scheduling, and conducting coding audits and maintaining records associated with coding reviews and/or audits of medical records for risk adjustment reporting.
• Reviews patient records in accordance to current compliance policies to analyze provider documentation to ensure that it meets standards and supports the diagnosis and procedure codes selected, including supporting medical necessity severity of illness and risk of mortality.
• Conduct audits on abstracted files to ensure accuracy and completeness of coding by identifying accurate coding opportunities and rechecking all diagnoses and procedures using ICD-CM (ICD-9 and ICD-10) and CPT-4 codes to ensure adherence to all official coding guidelines, federal and state regulations, health system and departmental policies and productivity standards.
• Demonstrates an understanding of hierarchical condition categories (HCCs), and participates in quality coding initiatives as appropriate or assigned.
• Assist in preparation and implementation of necessary internal controls for related entities consistent with CMS and State requirements to support RADV or other regulatory audits.
• Demonstrate knowledge of AHA Coding Clinic and ICD-CM (ICD-9 and ICD-10) Official Guidelines for Coding and Reporting, and possess the ability to share this knowledge with physicians and other patient care team members in a simplified and concise manner.
• Responsible for communicating with physicians to provide feedback on medical record review findings.
• Provides education on proper clinical documentation, compliance, and coding guidelines.
• Provide education and training to peers and providers, either in a one-on-one or group basis, on correct and efficient coding and documentation practices

Nice to Have:

• Specialty clinic experience.
• Enhanced knowledge of STAR, PAandR, IMS or other internal systems.
• Provider education experience.
• Compliant Physician query experience.

Required Skills and Experiences:

• Bachelors degree and 5 years of relevant health plan or provider office medical coding/claims and/or Business Analyst experience in a healthcare setting applicable to claims/coding, or 9 years of relevant health plan or provider office medical coding/claims and/or Business Analyst experience in a healthcare setting applicable to claims/coding in lieu of a degree.
• Previous experience in auditing medical records.
• Proficient knowledge of CMS-HCC model and guidelines.
• ICD-10 proficient.
• Coding Certification required (CPC, CCS, CCS-P, or RHIT) in good standing.
• CRC (Certified Risk Coder) in good standing, in addition to required coding certification.
• Attend continuing education classes to maintain coding proficiency and certification requirements.
• Risk adjustment methodology experience.
• HEDIS/STARS experience.
• Demonstrated ability to apply critical thinking skills to coding policy interpretation and implementation.
• Ability to travel (locally and non-locally) as determined by business need.