GENERAL SUMMARY:

RMRA (Revenue Management Risk Adjustment) Health Risk Coding and Education Specialist - Level II, specific to the Risk Adjustment Coding and Clinical Education team will perform retrospective, concurrent, and prospective chart reviews and audits under direction of the Manager/Lead. Identifies trends and educational opportunities for both administrative and coding/documentation processes. Engages and educates Health Alliance Plan in-network providers.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Auditing of medical records on a concurrent, prospective, and retrospective basis (including all vendor projects) to ensure compliance with applicable coding and documentation standards with an emphasis on diagnosis codes mapping to Hierarchical Condition Category (HCC).

• Assist with all aspects of The Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) mandatory audits including but not limited to coordination, documentation and coding of CMS Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) and vendor service project Risk Adjustment sampling audits.

• Complete appropriate paperwork, project documentation, and system entry requirements regarding claim/encounter diagnosis information for provider medical records, audits, and other special projects. Follow appropriate documentation storage and retention guidelines for all projects.

• Conduct HCC-focused reviews on providers including; tracking results and identifying trends and deficiencies for follow up training. Compile results for reporting to the health plan to assist in targeting deficient providers.

• Year-to-date, month-to-date, and real-time report generation to identify low risk score providers and providers whose HCC reporting is low in comparison to panel size.

• Effectively communicate the audit process and results to the appropriate department provider group and health plan.

• Assists with development of provider educational materials.

• Assists with development of provider education and outreach strategies.

• Completes outreach and engagement activities to the HAP provider network.

• Provides detailed health risk clinical documentation and coding education and training to providers, independent practice associations, vendors and internally within HAP and Henry Ford Health System (HFHS).

• Works with vendors, IPA & Provider offices, operations team and Provider Relations department to secure medical records.

• Maintains current knowledge of official ICD-10-CM coding guidelines, CMS documentation requirements and maintains a clear understanding of regulatory compliance.

• Facilitate workflow of all medical records received and work closely with medical records vendors to obtain medical records before project deadlines.

• Support and participate in process and quality improvement initiatives.

• Participate in continuing education activities to improve knowledge of job performance and to maintain credentialing.

• Abides by the American Health Information Management Association (AHIMA) Standards of Ethical Coding rules and guidelines to ensure high quality health information and accurate data submission to CMS and HHS. Complies with official coding conventions and the official coding guidelines to ensure high quality health information and data submission.

• Works with HAP Compliance Leads.

  EDUCATION/EXPERIENCE REQUIRED:

• Associate’s degree required in Health Information Management (HIM), Health Information Technology (HIT), healthcare, health service, or public health related field required.

• Bachelor’s degree or equivalent work experience in healthcare, health service or public health related field preferred.

• Two (2) years of coding experience in diagnostic and procedural coding required.

• Prior experience working with physicians/medical groups/physician offices preferred.

• Two (2) years of ICD-9-CM &ICD-10-CM coding experience/proficiency required.

• Prior healthcare related experience working with physicians/medical groups/physician offices preferred.

• Knowledge of medical billing and third party payer regulations preferred.

• Ability to get results with physicians and physician’s office staff to obtain medical records.

• Excellent communication skills and ability to work well with multiple HAP departments to get desired results.

• Knowledge of the release of health information processes and regulations.

• Knowledge of Health Insurance Portability and Accountability Act (HIPAA).

• Strong knowledge in ICD-10-CM coding and guidelines.

• Excellent quantitative, analytical, and problem solving skills.

• Excellent written and oral communication skills.

• Strong ability to work independently.

• Ability to work with automated systems.

• Ability to work across multi-disciplinary teams.

• Ability to organize and manage multiple priorities.

• Strong work ethic, reliable, resourceful, with enthusiastic attitude.

• Strong knowledge of anatomy, physiology, pathophysiology, disease processes, medical terminology, pharmacology, and coding systems.

• Knowledge in the use of Microsoft Office products.

• Knowledge of computer software programs used for data collection.

• Knowledge of Medicare Advantage risk adjustment payment methodology preferred.

• Knowledge of CMS programs, processes, and payment principles preferred.

• Knowledge of Adobe Pro preferred.

  CERTIFICATIONS/LICENSURES REQUIRED:

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC) required.

• Certified Coding Specialist (CCS), Certified Coding Specialist –Physician (CCS-P) preferred.

Additional Information

• Organization: HAP (Health Alliance Plan)

• Department: Revenue Management

• Henry Ford Health Location: HAP (Health Alliance Plan)

• Shift: Day Job

• Union Code: Not Applicable

  Additional Details

  This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

Benefits

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.