Risk Adjustment Quality Assurance Auditor Senior - Health Plan Admin at CHRISTUS Ministry System Office

Summary:

The Risk Adjustment Quality Assurance (RAQA) Auditor Senior will be involved with activities of compliance auditing and targeted quality assurance audits for the following programs, including but not limited to Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). This is a Texas-based remote position, and the candidate must reside within 150 miles of Irving, Texas. This role will be required to attend onsite leadership meetings and coder onboarding sessions.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• RAQA Auditor Senior performs quality assurance audits within multiple EMRs, databases, and vendor platforms to support employed and independent clinic or vendor/partner risk adjustment strategies.
• Perform quality assurance audits based on organizational priorities, including third-party audits. Audits include compliance review of prospective and concurrent Clinical Documentation Improvement (CDI) workflows and retrospective auditing.
• Conducts compliance review to ensure that rendered physician services for claim submission and subsequent payments are as accurate as possible while complying with regulatory guidelines, including CMS, DHS, and OIG.
• Work independently, under the supervision of department leadership, with demonstrated ability to source appropriate audit feedback while prioritizing and managing multiple projects, meeting all deadlines requiring timely audit outcomes and weekly coder performance scorecards.
• This role is expected to maintain a consistent coding accuracy rate of 95% or higher and be able to meet productivity standards established by leadership.
• Delivers clear, concise, and professional communications to leadership as necessary when coding and documentation are inadequate, ambiguous, or otherwise unclear for medical coding purposes within department timelines.
• Responsible for documenting and tracking coding team queries in the identified database.
• Understands and complies with policies and procedures for the confidentiality of all audit results, patient records, HIPAA, and system security.
• Prepare and perform compliance analysis and provide feedback on noncompliance issues detected through auditing.
• Conduct coding team onboarding training and education regarding risk adjustment to help ensure accurate CMS payment and improve care quality. Training sessions will occur at our onsite Irving, Texas, Corporate office or via remote virtual training sessions.
• Prepare and present audit trends in support of coding compliance committee risk adjustment strategy meetings.
• Provides measurable, actionable solutions to the Quality Assurance Manager that will result in improved accuracy for documentation and coding practices to ensure chronic conditions are recaptured annually.
• Assist Quality Assurance Manager by making recommendations for process improvements to enhance coding quality goals and outcomes further.
• Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations by using current ICD-10-CM manual and other suitable material.
• Maintains active professional certification and complies with all educational, professional, and ethical requirements.
• Must have excellent written and verbal communication skills.
• Must be able to drive within assigned areas or overnight travel for internal or external meetings.
• Must have capacity to attend remote provider meetings day/evening/weekends as needed within assigned regions as defined by manager/leadership.
• Possesses excellent written, verbal, and communication skills, as well as attention to detail.
• Must Demonstrate knowledge of health systems operations, including understanding reimbursement methodologies and coding conventions.
• Possesses advanced knowledge and understanding of HCC/Risk Adjustment, coding, and documentation requirements.
• Must stay current on applicable coding and documentation guideline changes and rules.
• Must work effectively and efficiently within a team environment.
• Must be adaptable to shifting priorities and demonstrates a willingness to do what it takes to meet team needs.

Job Requirements:

Education/Skills

• High School Diploma or equivalent required.

Experience

• 3 years of current hospital inpatient/outpatient or medical office coding experience required.
• 5 years of risk adjustment coding experience preferred.
• Prior experience teaching/training others on correct coding guidelines and the ability to present to large groups of physicians/providers and/or leadership required.

Licenses, Registrations, or Certifications

• One of the following certifications required through AHIMA or AAPC:
  • Certified Coding Specialist for Providers (CCS-P).
  • Certified Professional Coder (CPC).
  • Registered Health Information Management Technician (RHIT).
• Following certifications preferred through AHIMA, AAPC, or ACDIS:
  • Certified Risk Adjustment Coder (CRC).
  • Certified Professional Medical Auditor (CPMA).
  • Certified Documentation Expert Outpatient (CDEO).
  • Certified Clinical Documentation Specialist-Outpatient (CCDS-O).

Work Type:

Full Time

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