Risk Adjustment Coder

Job Description

It’s Time For A Change...

Your Future Evolves Here

Evolent Care Partners’ works directly with primary care organizations across the country to improve patient outcomes and reduce avoidable health care costs. We are a lean, nimble, and fast-paced team looking for innovators and disruptors with a passion for improving health care. Our team is made up of reliable, hard-working employees—each with a commitment to shaping our culture and strategy. This role presents a unique opportunity to get in on the ground floor of an internal start-up and leave your mark on health care.

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. We bring our whole selves to work, and we’re driven to make a difference every day, from the work we do in our roles to the charitable endeavors we support. We believe in starting by listening, communicating with candor, fostering inclusion, and owning the opportunity. We respect and celebrate individual talents and team wins. Whether we’re wearing scrubs, jeans, or our finest work-from-home chic, we have fun, work hard, and make time to help others.

Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving diversity, equity, and inclusion (DE&I) efforts. Evolent achieved a 100% score on the 2020 Human Rights Campaign's Corporate Equality Index, making us one of the best places to work for LGBTQ+ employees. We were also named on the Best Companies for Women to Advance List 2020 by Parity.org and we publish an annual Diversity Report to share our progress on how we’re building an equitable workplace and performing on various metrics. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

Who You’ll Be Working With:

Under the direction of the Senior Director, Risk Adjustment Coding Strategy, you’ll collaborate with other ECP team members, leaders and Providers as needed. This role is an intricate part of the Risk Adjustment coding team and ECP programs. The goal is to support ECP’s coding strategy, tactics, and data capture processes to drive overall optimal Risk Adjustment coding performance.

What You Will Be Doing:

ECP’s Risk Adjustment Coding Support Specialist will perform a comprehensive review of each Progress Note and will ensure the clinical documentation in the Progress Note supports the ICD-10 codes assigned to the claim to the highest level of specificity before submission. Compliance with Official Coding Guidelines in ICD-10-CM coding conventions, as well as CMS Risk Adjustment Data Validation (RADV) guidelines, is a must. The focus of this position is to confirm accuracy and specificity of diagnoses codes assigned on the claim are in accordance with the AHA ICD-10-CM coding guidelines, CMS clinical documentation guidelines, and RADV criteria.

This position may require communicating with the provider to obtain higher specificity for accuracy of code assignment. Clinical knowledge and high-level analytical skills are utilized in the review of each Progress Note to confirm support of appropriate ICD-10-CM code assignment for accuracy of risk score assignment and reimbursement. This role is specific to provider clinical documentation and the requirements of CMS for RADV and reporting.

Accurate coding with demonstration of knowledge in the principals and practices of ICD-10-CM and CPT conventions applies continuously. You must enjoy reading and demonstrate the ability to put clinical pieces of documentation together for diagnosis coding specificity, validation, and accuracy. Maintaining a high level of proficiency, productivity and accuracy with awareness and understanding of CMS RADV HCC compliance and guidelines will have you thriving in this position. Awareness, alertness, and the ability to understand the continuous changing guidelines and requirements for physician documentation and ICD-10-CM coding with excellent communication skills to mitigate risk to ECP is priority.

Primary Responsibilities:

With use of the current programs, EMR, tools and resources, r e vi e w ICD-10-CM diagnosis codes submitted on claims in conjunction with the clinical documentation in the Progress Note f o r ac c u racy of ICD-10-CM coding assignment to the highest l e v el of specificity i n a t i m e l y and ef f i c i e n t m a nn er, maintaining productivity and accuracy:

• Through Progress Note reviews, accurately communicate with providers using effective, necessary queries and communication through the specified method using only approved queries as this communication is part of the legal record. Prevent unnecessary interruption to Providers. Review all Provider queries, communications, and feedback with an open positive outlook. Build appropriate lasting relationships in the efforts to reduce Provider burn-out and mitigate risk.
• Ensure diagnosis coding and clinical documentation criteria, rules and guidelines have been met in accordance with ECP policy and CMS guidelines.
• Through Progress Note and clinical documentation reviews, recognize opportunities and trends for educational needs and outreach opportunities including, but not limited to, informatics, internal processes, and clinical workflow.
• Recognize clinical signs, symptoms, and indicators for gaining the highest level of specificity via Provider queries to appropriately represent our patient’s disease burden for accuracy of risk score assignment. This also assists the Providers with meeting and maintaining the CMS documentation requirements.
• Through Progress Note reviews and permissions, identify, and assist the providers in updating the patients Active Medical Problems List for diagnosis accuracy reflecting the highest-level specificity in the EMR descriptor and ICD code by appropriate methods.
• Maintain effective, positive, and appropriate communication to ensure that your productivity and accuracy standards are met.
• Actively par t i c i p a t e i n departmental provided se m in ar s, training and/or boot camps to re m a i n upd a t e d on any r u l e s a n d c h a n g es r e g a r d i n g diagnosis c o din g a n d do c u m e nt a t i o n requirements from a p p r o p r i a t e cr e d ib l e s ou r ce s. Although ECP will do its best to supply resources for continued education, you will need to independently seek CEU’s if needed to m a i n t a i n your certification cr e d e n t i a l s through A A P C/AHIMA specific to your role.
• Communicate and interact w i t h Practice Performance Advisors, b i l l in g and/or c o di n g compliance t e a m s re g a r d i n g p r o p er c o d i n g a n d d o c u m e nt a t i o n r e q u i re m e nt s a n d p r o c e ss e s . Pre s e n t applicable questions, suggestions and/or in f o r m a ti o n i n a ti m e l y m a nn er, as a p p r o p r i a t e, a n d maintain awareness and understanding o f i n t e r n a l p r o c e s s e s .
• Review all documentation ethically and thoroughly within the Progress Note using all applicable tools and resources (AHA coding clinic, ICD-10-CM/CPT manual, CMS guidelines, coder ethics, official coding guidelines), including communication with your supervisor, to apply understanding, knowledge, and skill set. Send queries to physicians where necessary.
• Assist in the development and implementation of strategy for ECP’s risk adjustment and coding accuracy ensuring compliance with regulatory requirements.
• Challenge status quo and develop innovative and out of box solutions to drive coding accuracy and optimization.
• Observe market performance and provide guidance where needed to ensure market success in programs developed.
• Contribute to the creation and maintenance of coding materials, review processes, workflow documents and policy & procedure implementation surrounding coding guidance and coding standards.

The Experience You’ll Need (Required):

• Certified Risk Adjustment Coder certification (“CRC”) with experience working with Primary Care Providers, Payers and/or Billing including knowledge of ICD-10-CM diagnosis coding guidelines
• 2+ years in a Risk Adjustment HCC coding role
• Ability to demonstrate accurate diagnosis code look up using the index to tabular in a current AHA ICD-10-CM expert for physicians coding manual (ECP will provide yearly updates)
• Demonstrated ability to work productively, accurately, and independently
• Accountability to consistently meet daily productivity expectations while maintaining a pre-determined level of coding quality and accuracy standards as set forth by the Risk Adjustment Department
• High sense of confidentiality to protect patient health information and data according to HIPAA security
• EHR experience with the ability to demonstrate how to navigate and research appropriately
• Ability to travel to Partner sites if needed (Tier II or higher)
• Awareness of ethical coding, the official coding rules, regulations, and coding conventions of the American Hospital Association (Coding Clinic), ICD-10-CM, Centers for Medicare and Medicaid Services (CMS), and organizational/institutional coding guidelines

Finishing Touches (Preferred):

• Bachelor’s Degree
• RHIT /RHIA through AHIMA
• Hands-on clinical experience (CNA, LPN, RN, MA)
• Working knowledge of anatomy, physiology, and pathophysiology to understand disease processes, treatment, or management of conditions
• Experience with MSSP ACO program, Value Based Care and/or Medicare Advantage
• Experience working within variety of EMRs
• 2+ years of experience with analyzing risk adjustment and quality performance data
• Experience leading a team of HCC coders to drive performance improvements
• Client management experience, having demonstrated an ability to communicate effectively and partner with practices with the ability to engage, inspire, build credibility, and engender trust across all levels of an organization
• Attention to detail, identify gaps and needs to improve organizational success
  

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. Evolent Health maintains a drug-free workplace.