Risk & Documentation Improvement Coder

Job Summary:  To actively participate in quality improvement by closing Hierarchical Chronic Condition (HCC) gaps on payer portals.  Work in tandem with care coordinators on portal work.  Participate in payer phone calls, meetings and trainings related to HCC work.  To assess provider documentation trends, propose improvements and meet with providers to coach the recommended changes.   To accurately assign a CPT code(s), HCPCS code(s), CPT-4 modifier(s) and all applicable ICD-10-CM codes to all assigned patient encounters and procedures in a timely manner.

Typical Requirements:

1. Completion of high school or equivalent.
2. Current coding certification; CPC, CCA, or CCS-P.
3. Experience using CPT, CPT-II, CPT-4, HCPCS and ICD-10-CM codes.
4. Organizational skills.
5. Ability to communicate clearly, professionally and courteously; effective listening, writing, spelling, and reading skills. Communication skills must support face-to-face, telephone and written communication methods.
6. Ability to follow oral and written instruction.
7. Knowledge of medical terminology and common chronic diseases.
8. Knowledge of human anatomy and physiology.
9. Basic computer skills; familiarity with keyboard, 10-key, mouse, basic Microsoft operating system functionality, Outlook, Word and Excel.
10. Ability to work quickly and accurately.
11. Ability to interact with coworkers and providers tactfully, to be a team player.
12. Ability to utilize independent and sound judgment to accomplish assigned responsibilities.
13. Ability to self-direct and multitask.
14. Ability to be flexible and adaptable to changing assignments and work pace.

Preferred Qualifications: 

1. Completed educational program for medical coding focused on coding for risk.
2. Completed educational program for medical coding focused on clinical documentation improvement.
3. One year experience coding for RAF in an ambulatory setting.
4. Current coding certification; CRC, CPMA, CDEO and/or CDIP
5. Familiarity and knowledge of CMS Hierarchal Condition Categories
6. Knowledge of coding software (such as Encoder Pro)
7. EHR familiarity

Essential Functions – HCC (Hierarchical Condition Category):

1. Review HCC gap lists via access to payer portal.
2. Research medical record to identify information to confirm or invalidate HCC gap.
3. Close HCC gap by uploading appropriate medical record documentation to payer portal.
4. Communicate with insurance representatives by email and phone.
5. Attend routine meetings with payer representatives to review HCC status and progress, review incentive programs and obtain payer specific education.
6. Flexibility in schedule to meet early bird and end of year deadlines.

Essential Functions – CDI (Clinical Documentation Improvement):

7. Abide by a schedule to assess provider documentation trends in accordance with current documentation guidelines as defined by the AMA and CMS.
8. Evaluate documentation opportunities to support a higher level of HCC recapture compliance for providers.
9. Identify documentation opportunities to better support appropriate reimbursement for services rendered.
10. Prepare recommendations related to documentation opportunities.
11. Meet with providers to present findings and suggestions. Apply coaching techniques as needed.  Follow-up with providers after meetings to provide additional support.
12. Assist with provider documentation audits.

Essential Functions – Coding:

13. Assign ICD-10-CM, CPT, CPT-II, CPT-4 and HCPCS codes to patient encounters and procedures.
14. Keep up-to-date on changes in coding guidelines and requirements.
15. Maintain patient confidentiality.
16. Ability to use Epic, EncoderPro.com, Outlook, Microsoft Excel, and Microsoft Word computer systems. Ability to navigate internet sites to research coding guidelines.