This is a fully remote position, open to applicants in South Dakota, +1 more state.

📋 Description

• Perform quality assurance tasks to guarantee the accuracy and integrity of risk adjustment data submitted to CMS and DHS.

• Detect deficiencies and provide management with analysis regarding outcomes and tools aimed at enhancing coding accuracy.

• Create, implement, and oversee a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange, and Medicaid/BadgerCare Plus member diagnosis documentation.

• Review medical record documentation to uncover uncoded or incorrectly coded diagnoses.

• Conduct audits on coding for visits and procedures documented by physicians, hospitals, and other providers across various specialties and subspecialties as they relate to HCC coding.

• Stay informed about CPT, ICD-9, ICD-10, HCPCS, HCC coding, modifiers, documentation guidelines, CMS policy requirements, and reimbursement guidelines.

• Compare provider documentation with reported code requirements to ensure coding support.

• Summarize audit outcomes and present findings in a clear and concise manner.

⛳️ Requirements

• High school diploma or equivalent is required.

• Proven knowledge of anatomy/physiology and medical terminology.

• Completion of courses in Current Procedural Terminology and ICD‐9 and ICD‐10 coding is required.

• A minimum of three years of experience in a health insurance, compliance, quality assurance, or auditing-related role is required.

• Experience with ICD‐9, ICD‐10, CPT, HCC, and HCPCS coding is necessary.

• Understanding of CMS guidelines impacting Medicare Advantage, HHS‐ACA, and DHS/BadgerCare Plus members in relation to revenue management.

• Proficient knowledge of Word, Excel, and Access.

• Certification as a Professional Coder and/or Certified Risk Adjustment Coder from the American Academy of Professional Coders is required within one year of employment.

• An Associate Degree in coding and/or a health-related field is preferred.