Quality Assurance Coder/Auditor

Quality Assurance Coder/Auditor

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 Adjustable provider. Coder/Auditor will perform QA for vendors and other submitters of supplemental HCC data and provide educational feedback relevant to same.

Required Work Experience: 5 years of professional coding experience, with at least 3 years of HCC coding experience, and 2 years of HCC auditing 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 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:

• Demonstrate comprehensive understanding of HCC Coding rules, regulations, methodology and the role of hierarchies
• 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
• Perform QA audits on vendor and provider group supplemental data submissions. Provide corrective action recommendations when accuracy scores fall below 95%
• 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.
• Develop effective provider/coder education program in support of risk mitigation analysis. This includes writing education tips for BCBSAZ publications and preparing materials for presentation during Zoom calls
• Correct encounter rejections within vendor platform
• 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 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
• Strong writing skills
• Ability to prepare and present PowerPoint slides
• Ability to create Excel spreadsheets and perform basic functions in Excel
• 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

Our Commitment:

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.

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.