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Henry Ford Health System Health Risk Coding & Education Specialist II - Health Alliance Plan in Southfield, Michigan

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.

  • Perform other duties as assigned.

EDUCATION/EXPERIENCE REQUIRED:

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

  • 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 physicians' 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.

  • Ability to work across multi-disciplinary teams.

  • Ability to organize and manage multiple priorities.

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

  • 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.

    Overview

    Under the leadership of President and CEO Wright L. Lassiter, III, Henry Ford Health System is a

    $6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites

    including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and

    other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system

    now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one

    of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the

    health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s

    major academic medical centers, receiving between $90-$100 million in annual research funding and

    remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical

    education and training, the health system has trained nearly 40% of physicians currently practicing

    in the state and also provides education and training for other health professionals including nurses,

    pharmacists, radiology and respiratory technicians. visitHenryFord.com.

    Benefits

    Whether it's offering a new medical option, helping you make healthier lifestyle choices or

    making the employee enrollment selection experience easier, it's all about choice. Henry

    Ford Health System has a new approach for its employee benefits program - My Choice

    Rewards. My Choice Rewards is a program as diverse as the people it serves. There are

    dozens of options for all of our employees including compensation, benefits, work/life balance

    and learning - options that enhance your career and add value to your personal life. As an

    employee you are provided access to Retirement Programs, an Employee Assistance Program

    (Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness, and a whole host of other benefits and services. Employee's classified as contingent status are not eligible for benefits.

    Equal Employment Opportunity/Affirmative Action Employer

    Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System 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.
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