Senior Risk Adjustment Specialist

Job Summary

The Senior Risk Adjustment Specialist reviews medical records to ensure all ICD-10-CM codes are accurate and compliant with supportive documentation for submission to the Centers for Medicare and Medicaid Services (CMS). This role is a resource for the Risk Adjustment Specialists and provides subject matter expertise.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage


• 401(k) Savings Plan with company match and immediate vesting


• Paid Time Off (PTO)


• 9 Paid Holidays annually plus a Floating Holiday to use as you choose


• Tuition Assistance


• Flexible Spending Accounts


• Healthcare Reimbursement Account


• Paid Parental Leave


• Community Service Time Off


• Life Insurance and Disability Coverage


• Employee Wellness Program


• Training and Development Programs to develop new skills and reach career goals


• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Key Responsibilities

• Maintain thorough understanding of the risk-adjusted payment methodology; what can be submitted by the plan and how/when submission impacts CMS payments.


• Demonstrate knowledge of ICD10 coding guidelines, medical terminology, disease processes, and pharmacology.


• Interpret and demonstrate analytical and problem-solving ability to accurately assign ICD10 codes that are clinically identified and supported in the medical record.


• Work with department management to communicate provider coding accuracy concerns and challenges.


• Ability to identify HCC improvement opportunities and educate clinical providers on proper clinical documentation, compliance, and coding guidelines.


• Report findings of chart audits and Clinical Documentation Improvement (CDI) opportunities to providers to maximize the coding of ongoing risk adjusted conditions.


• Query providers when necessary to obtain clarification for unclear documentation.


• Collaborate with providers regarding coding changes, questions concerning documentation, diagnosis coding, and level of service.


• Conduct chart reviews to identify clinically supported diagnoses based on CMS-HCCs and specific HEDIS measures.


• Support any ongoing program that minimizes any organizational risk in the event of a Risk Adjustment Data Validation (RADV) audit.


• Communicate with Department Management to keep abreast of potential risk exposure related to coding and/or documentation practices by providers and/or coding personnel.


• Provide support and compliance through effective communication and training/education.


• Train and mentor new Risk Adjustment Specialists.


• Assist management with workflow improvements and process optimization.


• Serve as an escalation point for complex coding questions and issues.


• Monitor provider coding performance and trends.


• Evaluate coding practices for regulatory and compliance risk.


• Support RADV audits, validations, and related projects.

REQUIRED QUALIFICATIONS:

• High School Diploma or GED


• At least 5-7 years' experience with coding


• Certified Coder (AHIMA or AAPC credentials)


• Read and interpret handwritten and typewritten medical documentation


• Ability to work under pressure to meet deadlines with minimal supervision


• Basic computer skills


• Ability to maintain flexible work schedule to meet department needs required


• Demonstrate excellent customer service sills through written and verbal communication


• Demonstrate leadership among coding team

PREFERRED QUALIFICATIONS:

• 2 or more years of college


• Experience with hospital coding