Medicare Risk Adjustment Coding Specialist- Remote

American Health PlansFranklin, TN

Apply with Sonara

Automate your job search with Sonara.

Submit 10x as many applications with less effort than one manual application.¹

Reclaim your time by letting our AI handle the grunt work of job searching.

We continuously scan millions of openings to find your top matches.

Overview

Remote

On-site

Job Description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Benefits and Perks include:

Affordable Medical/Dental/Vision insurance options
Generous paid time-off program and paid holidays for full time staff
TeleDoc 24/7/365 access to doctors
Optional short- and long-term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program

JOB SUMMARY:The Medicare Risk Adjustment Coding Specialist is responsible for conducting coding audits prior to payment release. Additionally, this position will perform post-payment coding reviews with overpayments and will in turn send coding education correspondence to applicable providers.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes based on services rendered.

Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement

Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured

Develop tools and metrics to improve accuracy and completeness of coding and documentation

Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards

Escalate appropriate coding audit issues to management as required

Participate in and support ad-hoc coding audits as needed

Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit

Work assigned coding projects to completion

Other duties as assigned

JOB REQUIREMENTS:

Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment to include the review of regulatory announcements via educational sessions provided by regulatory entities and educational opportunities within the industry

Follow all appropriate Federal and state regulatory requirements and guidelines, as well as company policies and procedures

Maintain established levels of production and quality standards

Knowledgeable of CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations

Knowledgeable of coding/auditing claims for Medicare and Medicaid plans

Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing

Strong interpersonal skills

Excellent written and verbal communication skills

Strong organizational skills; ability to time manage effectively

Maintain confidentiality

Strong analytical and critical thinking skills required

Ability to work remotely without direct supervision

Successful completion of required training

Handle multiple priorities effectively

REQUIRED QUALIFICATIONS:

Education:

o High school or equivalent degree

Experience:

o 2 years’ experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system

o 2 years’ experience in managed healthcare environment related to claims and/or coding audits

o 2 years’ experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others

o 2 years’ experience with CMS requirements regarding claims processing and coding, especially skilled nursing and other complex claim processing rules and regulations

o 2 years’ experience coding/auditing claims for Medicare and Medicaid plans

o Significant HCC experience (including knowledge of HCC mapping and hierarchy)

License/Certification:

o Coding certification required (CPC or CRC)

Travel may be required

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EQUAL OPPORTUNITY EMPLOYER

This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.

This employer participates in E-Verify.

Education

Preferred

High School or better
GED or better

Licenses & Certifications

Preferred

ICD-10 Coding

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Automate your job search with Sonara.

Submit 10x as many applications with less effort than one manual application.

Apply with Sonara Apply manually

FAQs About Medicare Risk Adjustment Coding Specialist- Remote Jobs at American Health Plans

What is the work location for this position at American Health Plans?

This job at American Health Plans is located in Franklin, TN, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.

What pay range can candidates expect for this role at American Health Plans?

Employer has not shared pay details for this role.

What employment applies to this position at American Health Plans?

The employer has not provided this information. This may be discussed during the hiring process.

What is the process to apply for this position at American Health Plans?

You can apply for this role at American Health Plans either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.