The CHRISTUS HCC Coding & Encounter Data Manager reports to the Director of Business Intelligence and Risk Adjustment Analytics. This position provides leadership, and direction to the Encounter Data Team (EDT) as well as support to the Director. This position will be responsible for reviewing and auditing inpatient, outpatient, and professional clinical documentation and diagnostic results to apply appropriate ICD-9/10-CM /CPT codes for internal and external reporting, research, and regulatory compliance. Also, conduct chart coding, audit reviews, and monitoring and reporting of KPIs for the purpose of submitting accurate diagnosis codes to the Centers for Medicare and Medicaid Services, and providing feedback for educational purposes related to Coding/Documentation Guidelines and Risk Adjustment.
The HCC Coding & Encounter Data Manager works collaboratively with the Health Plans Business Intelligence, Encounter Data, Claims, Configurations and Eligibility departments on a number of projects, updates, and education initiatives. As a Manager, this position ensures that all coding and encounter data operations are standardized, meet regulatory requirements, and supports operation and reimbursement initiatives. This position performs timely monitoring and analysis of Medicare and Healthcare Exchange HCC coding operations to ensure performance objectives are met to support quantity and quality. The HCC Coding & Encounter Data Manager is expected to maintain effective professional relationships as appropriate to instruct, share ideas, and implement actions related to coding functions and encounter data improvements.
- Train new & prospective coders; and cross train Encounter Data team in new areas
- Participate in performance improvement activities
- Implement and direct coding processes that are compliant and efficient
- Review workflow processes and balance distribution of assignments in coding/encounter data department to meet targets
- Acts as a resource for the encounter data and coding staff and serve as a liaison to the Director to address Encounter Data/Coding related issues and questions
- Disseminates changes in coding rules such as correct coding initiative and Coding Clinic. Monitor changes in laws, regulations, and policies that impact clinical documentation, reimbursement, and coding to assure compliance
- Assures codes are supported by provider documentation and initiates appropriate queries based on clinical documentation for accurate and reliable data collection and reimbursement
- Analyzes and interprets Healthcare Exchange & Medicare encounter data to identify potential issues and trends.
- Define acceptable billing practices for multiple provider types, based on the plan (Healthcare Exchange, Medicare Advantage, and U.S. Family Health Plan).
- Coordinates with other department and performs the correction of encounter data rejections so that files may be resubmitted, error-free.
- Monitors daily administrative duties of the encounter data process. This includes a key point of contact with encounter application vendor regarding encounter processing, a direct response to external and internal customers' issues which may arise, ensuring resolution.
- Produce statistical reports for researchers, financial and business planning that measure physician's/hospital's efficiency, and for reports to State and federal agencies.
- Oversee coding education by preparing and completing materials for internal and external audits, regulatory changes, and other changes in medical advancements
- Ensures timely, accurate, and complete clinical data for billing, reimbursement, utilization, and patient information systems
- Report to the Director ongoing quality assessments: Perform audits for compliance, maintain the accuracy of coding performed, oversee capture rate (Adds, Deletes, Validations) and analysis of data regarding operational performance and quality control, ensure all coding is completed with quality and regulatory compliance as the primary objective
- Bachelor's degree preferred or equivalent Risk Adjustment coding leadership experience.
- Health care insurance and medical coding, billing and payment guidelines knowledge required
- Intermediate to advanced Excel Skills.
- 2+ years health care industry experience within managed care.
- 2+ years Management experience preferred.
- At least 2 years of experience in HCC, a clinical, Healthcare operational, or data quality improvement function.
- Experience with benchmarking performance and/or standards against identified criteria.
- Extensive knowledge of ICD-9-CM, ICD-10-CM/PCS and CPT and HCPCS coding principles and billing guidelines.
- Experience in conducting medical record audits reviews required.
- Experience with CMS Risk Adjustment Data Validation Audits, preferred.
- Familiarity with CMS Guidelines & Encounter Data Submission, preferred.
- Familiarity working with EDGE Encounter Data, EDS Encounter Data & RAPS files.
C. Licenses, Registrations, or Certifications
- Medical Coder with documented designation from an accredited source such as American Health Information Management Association or American Academy of Professional Coders (CPC-H, CCS, CCA, etc.) required
- CRC (Certified Risk Adjustment Coder) certification, preferred.