- Confirm all risk adjustment diagnosis codes from acceptable provider documentation and in accordance with industry standards, CMS or HHS Risk Adjustment Guidelines
- Adherence to current industry standard as defined in the ICD-10 guidelines for coding and correct reporting
- Confirm accurate entry of risk adjusted codes into internal/external data based as defined by State, Federal or other Regulatory Agencies.
- Support in documentation retrieval and review during Medicare or Exchange RADV Audits
- Ability to support strategic direction for program operations, goals, metrics, tasks, timeframe and appropriate reporting and timing related to all National HCC Activities.
- Identify and apply best practices to ensure accuracy of risk adjustment coding is consistent across in all markets served by Neighborhood Health Plan
- Reconcile data to outcomes, and Risk Scores and Trending patterns to RAF Scores
- Monitor risk adjustment relates activities including but not limited to risk adjustment program payments, encounter data submission and return files to ensure all tasks are completed in a timely manner and achieve expected outcomes
- Support new initiatives in the develop and standardization of tools to be used to improve accuracy of coding and documentation that meet State and National Standards
- Consistently exhibit behaviors and foster relationships with peers and internal stakeholders
Regulatory Oversight and Quality Assurance:
- Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
- Support strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.
Provider Engagement, Training and Support
- In Partnership with Manager of Risk Adjustment, support internal departments in proper coding, on error rates associated with coding accuracy to ensure data is complete and accurate prior to submission to external agencies.
- In conjunction with other departments, support programs that will enhance provider training and education of the HCC Risk Adjustment Process, Proper Medical Record Documentation and Diagnosis Accuracy.
Analysis and Use of Results
- Support Manager with Medical Management on the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.
- Collaborate with Manager to project and monitor the impact of coding programs on CMS revenue for budgets and plans
Enterprise Risk Adjustment
- Support Manager in driving enterprise-wide risk adjustment initiatives.