Lead Hierarchical Condition Category (HCC) Coding Specialist (Remote)

Company : Highmark Inc. Job Description : JOB SUMMARY This job will deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs (MA and ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, CMS coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Conducts quality assurance (QA) review of internal coding team members, provides coding education to team, evaluates HCC coding questions and independently renders guidance on appropriate coding determinations. The incumbent supports RADV audits, specializing in performing second level review of HCC validation and research of outstanding HCCs; prepares documentation and coversheets for upload to regulatory body and/or independent auditor, and analyzes results. May also be responsible for high-priority and key strategic provider entities and/or anchor partners to analyze and evaluate coding trends; proactively identify issues and present solutions to internal leadership and external entities; leads activities with provider entities. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and/or compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding. Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums. May also complete analysis on provider coding trends create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis. ESSENTIAL RESPONSIBILITIES Conducts Quality Assurance (QA) reviews on internal coders, at minimum, bimonthly for coder score and education/feedback to coder. Monitors the QA Questions Queue, independently researches questions using appropriate sources, including AHA Coding Clinic®, and responds to questions from all coding teams (retrospective, prospective, and audit). Publishes QA question & responses and presents education on monthly team meetings. Conducts Quality Assurance reviews on vendors monthly or per contract SLA. Provides education/feedback to the vendor. Conducts quality reviews of high-risk and incremental HCCs and applies expertise to analyze documentation and mitigate risk to the organization. May support external vendor quality review(s) to measure coding accuracy, prepare and report findings, and monitor accuracy. Collaborates with team members to optimize data collection and review, provider education and outreach, and coding quality. (20%) Plays an integral role in the completion of all Government Audits, including Improper Payment Measure (IPM), CON-RADV, ACA-RADV, and Office of Inspector General (OIG), as applicable. Applies extensive clinical and coding knowledge and abilities, independently conducts coding research, aligns all aspects of audit, including coding adjudication and rebuttals with audit vendor, obtains provider attestations, identifies & obtains missing medical records, compares audit results to claims, and thoroughly reviews all in-house charts in chart repository for validation of audit. Prepares documentation and coversheets for upload to regulatory body or independent auditor. (20%) Responsible for high priority and key strategic provider entities and/or anchor partners to analyze and evaluate coding trends; proactively identify issues and present solutions to internal leadership and external entities. Leads engagement activities with the provider entity. Provides support for entity and acts as liaison between all provider facing team. Conducts data analyses from medical record reviews; proactively summarizes opportunities to enhance provider documentation to improve coding accuracy and thorough capture of members’ chronic health conditions. Completes analytics on providers and/or provider group coding trends and creates and delivers externally facing presentations to provider documentation and accuracy, act as the point person for the provider office for any questions and additional trainings, as needed. (20%) Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures to guide HCC coding decision making. Achieves and maintains coding productivity and quality accuracy metrics set by the management team. (10%) Executes assigned projects in accordance with project plans; monitors progress and makes adjustment as necessary to ensure successful completion. Participates on ad-hoc projects per the direction of leadership to address the needs of the department. (10%) Develops and presents process improvement and training initiatives to improve efficiency and accuracy of departmental coding practices. Regularly presents and contributes to coding education meetings and Annual Coding Summit. Adapts presentation style to audience; provides constructive feedback; presents in-person, virtually and/or by webinar. (10%) Mentors new hires and coworkers on CMS and Highmark coding guidelines and contributes to onboarding and training material development and enhancement. (10%) Other duties as assigned or requested. EDUCATION Required Associate's degree in medical billing/coding, health insurance, healthcare or related field, or relevant experience and/or education as determined by the company in lieu of bachelor's degree Preferred Bachelor's degree in medical billing/coding, health insurance, healthcare or related field EXPERIENCE Required 5 years of HCC risk adjustment coding experience Preferred 7 years of HCC risk adjustment coding experience 3 years of RADV audit experience 3 years of Coding QA experience 3 years of LPN or RN experience 1 years of Management or leadership LICENSES or CERTIFICATIONS Required (any of the following) Certified Professional Coder (CPC) Certified Risk Coder (CRC) Certified Coding Specialist (CCS) Registered Health Information Technician (RHIT) Preferred None SKILLS Critical Thinking Attention to Detail Strong Verbal and Written Communication Skills, including Presentation Skills Ability to objectively analyze facts and form judgments Ability to handle manage projects to a successful outcome Strong interpersonal skills Ability to identify and resolve problems Ability to work in a fast-paced, collaborative environment with minimal supervision Extensive knowledge of medical terminology and ability to research coding-related questions Strong clinical knowledge related to chronic illness diagnosis, treatment, and management Microsoft Office Suite Proficient - MS Word, Excel, Outlook, PowerPoint, MS365 and Teams Language (Other than English): None Travel Requirement: 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Remote Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Occasionally Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $72,700.00 Pay Range Maximum: $116,600.00 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at View email address on click.appcast.io California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.