Medicare Risk Adjustment Manager: Catholic Health Care System (CHCS) (HQTRS)

Medicare Risk Adjustment Manager

1. Responsible for the overall administration and supervision of the Hierarchical Condition Categories (HCC) conditions program that are applicable to Medicare Risk Adjustment reimbursement..

1. Provides technical guidance to physician, nurse practitioners and other staff in identifying and resolving issues such as incomplete or missing documentation, ambiguous or nonspecific documentation or codes that do not conform to approved coding principles/guidelines.

1. Educates and advises staff on proper code selection, documentation, procedures and requirements; identifies training needs, prepares training materials and conducts training for physicians, nurse practitioners and other staff to improve skills on quality documentation and in the collection and coding of health data.

1. Reviews bulletins, newsletters and periodicals and attends workshops and seminars to stay abreast of current issues and trends and changes in law and regulations governing medical record documentation and coding.

1. Develops and updates policies and procedure manual to maintain standards for correct coding minimize the risk of fraud and abuse and ensure appropriate and accurate revenue and payment.

1. Performs validation audits to evaluate medical record documentation and encounter coding to ensure that diagnostic coding accurately reflect and support relevant coding based on Hierarchical Condition Categories conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives.

1. Reviews medical record documentation, interprets information such as diseases or symptoms and diagnostic descriptions for given visits, to accurately assign and sequence the correct ICD-9-CM codes, and report additional HCC data to CMS in order to realize the appropriate level of revenue.

1. Performs retrospective audits and interpretation of medical documentation to ensure capture of all relevant coding based on CMS HCC conditions that are applicable to risk adjustment reimbursement initiatives.

1. Develops reporting schedule, performs trend analysis, track the financial impact of identified additional HCCs, prepare reports for distribution and makes recommends action and implements change.

1. Generates, distributes, monitors visit/encounter forms are completed, received and data is entered into claim system to meet submission calendar.

1. Determines vendor services needed for coding audits, monitors performance of contracted vendor services and reviews costs of vendor services in accordance with contract, validates contracted vendor invoices and ensure billing accuracy.

1. Works closely with contracted vendors to coordinate and reconcile RAPS reply files with submission files to the encounter level, correct rejected data.

Bachelors in a health care related field required.

Minimum of five (5) years experience with ICD-9-cm and CPT coding guidelines, medical terminology, anatomy and physiology, Medicare reimbursement guidelines.

Knowledge of Medicare Risk Adjustment methodolog along with

knowledge of State and Federal regulations, also, knowledge of CQI methodologies.