Quality Assurance Coder/Auditor - Hybrid

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one‑on‑ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona. Purpose of the Job The Quality Assurance Coder/Auditor will develop a risk mitigation and provider education program. On a regular basis, Coder/Auditor will educate primary care providers and their staff on their historical diagnoses/coding error trends, accurate completion of medical record documentation, and at‑risk code identification and risk mitigation. This includes the review, analysis, and recommended coding based on medical and clinical diagnoses, procedures, injuries, or illnesses contained in medical records and supporting documentation. The Quality Assurance Coder/Auditor will perform risk mitigation analysis using available vendor tools to identify at‑risk single occurrence of HCCs and OIG targets. Deletions will be submitted for unsupported/invalid diagnoses. This analysis combined with QA findings and EDPS claims errors will drive the content and audience for provider education. The Quality Assurance Coder/Auditor will perform medical record reviews and abstract codes – to the highest specificity effectively from medical records based on the documentation provided. Coder/Auditor is responsible for ensuring diagnosis codes selected come from a face‑to‑face visit with a valid Risk Adjusted provider. Coder/Auditor will perform QA for vendors and other submitters of supplemental HCC data and provide educational feedback relevant to same. Required Qualifications Required Work Experience 5 years of professional coding experience, with at least 3 years of HCC coding experience. Advanced knowledge of coding guidelines. Required Education High School Diploma or GED in general field of study. Required Licenses N/A Required Certifications Certified Coding Specialist – Physician Based (CCS‑P), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Outpatient Coding (COC) credential. Preferred Qualifications Preferred Work Experience 5 years of Medicare Advantage health plan experience. 5 years of experience with HEDIS measures and/or the CMS Star Program. Preferred Education N/A Preferred Licenses Clinical training (Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant). Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (RHIA). Preferred Certifications Certified Documentation Expert Outpatient (CDEO), Certified Professional Medical Auditor (CPMA). Essential Job Functions and Responsibilities Comprehensive understanding of HCC Coding rules, regulations, and methodology. Review medical records and supporting documentation, determine completeness and accuracy of medical records and supporting documentation, identify and eliminate barriers to correct coding, and recommend best coding practices and improvements. Determine valid encounters, including face‑to‑face, legibility and valid signature, according to Medicare Managed Care requirements. Track QA audits and send out monthly updates to Vendor and management team. Updates include report findings and recommendations regarding closing healthcare gaps, medical record documentation, coding, and additional educational training to management. The goal is >95% accuracy in QA audits. Accurately and efficiently conduct medical record review/abstraction services. Develop effective provider/coder education program in support of risk mitigation analysis. Travel to physician offices, conduct on‑site educational training on how to close identified health care gaps, accurately document in medical record, and submit claims with correct coding. Track educational training sessions by date, provider, topic, number of attendees, etc. Other duties as assigned. Maintain current knowledge of the Medicare Managed Care Manual, Chapter 7 – Risk Adjustment and Medicare outpatient billing systems/processes. Maintain coding certification, and stay current with the numerous changes in risk adjustment methodologies. The position requires a full‑time work schedule. Full‑time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. Required Competencies Required Job Skills Excellent understanding of the CMS crosswalk of ICD diagnosis codes to Hierarchical Condition Category (HCC) codes and impact of diagnosis coding on risk adjustment payment models. Sufficient knowledge of anatomy, pathophysiology, and medical terminology necessary to correctly code diagnoses according to CMS and ICD‑10 coding guidelines. General knowledge of the provisions contained in Chapter 7 – Risk Adjustment, Medicare Managed Care Manual. Computer proficiency in an MS‑Windows environment, including MS Word, Excel, and PowerPoint, and ability to learn organizational systems and software applications. Basic knowledge and understanding of primary care provider office practices, electronic and manual medical record systems, and billing processes. Required Professional Competencies Ability to develop training materials and conduct educational training to close healthcare gaps, improve medical record documentation, and ensure complete and accurate coding. Ability to identify and effectively communicate medical record documentation and/or correct coding deficiencies to providers and their staff. Required Leadership Experience and Competencies N/A Preferred Competencies Preferred Job Skills Strong understanding of the Risk Adjustment Validation Audit (RADV) process for risk adjustment models. Pharmacology knowledge. Preferred Professional Competencies N/A Preferred Leadership Experience and Competencies N/A AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. #J-18808-Ljbffr Blue Cross Blue Shield of Arizona