Risk Adjustment Medical Coding Specialist (HCC/ PCC)
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Purpose of the Job
The Risk Adjustment Medical Coding Specialist performs medical record retrieval and review, ensuring compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment.
Essential Job Functions and Responsibilities
- Ability to review submitted medical records and abstract all codes that map to a Risk Adjusted HCC and/or RxHCC, with specific emphasis on identifying the most accurate severity of illness according to CMS guidelines.
- Ensure reviewed medical records meet all CMS standard requirements for valid HCC Submission.
- Participates in the retrieval of medical records, both onsite and through EMR access, and acts as a risk adjustment liaison to provider offices, following up on outstanding and incomplete provider billing summaries to ensure proper coding.
- Support Risk Adjustment Data Validation Audits, including but not limited to: chart retrieval and review for completion, obtaining attestation if needed, and compiling of files in preparation of IVA.
- Participates in outreach/intervention strategy and ongoing development to determine best practices approach with members and providers to assist in improving risk adjustment factors.
- Performs comprehensive 1st pass reviews of medical records and physician assessment forms, maintaining coding accuracy levels of greater than 90%.
- Verifies accuracy, completeness, and appropriateness of diagnosis codes based on basic to moderately complex medical documentation provided.
- Ensure compliance with established coding guidelines, RADV protocols, regulations and accreditation guidelines.
- Complies with policies and procedures for confidentiality of all patient records and security of systems.
- Ensure timely and accurate maintenance of coding-related documentation for internal and external users.
- Constantly pursue process improvements to increase chart retrieval rates.
- Attend pertinent coding seminars and training, and use other resources as applicable, to maintain current knowledge of rapidly changing coding guidelines.
- Demonstrates advanced knowledge of medical terminology, anatomy and physiology.
- Independently represent coding and medical record retrieval team interests on cross-divisional committees or projects.
- Demonstrate complete ownership and accountability in all leadership roles, process improvements and recommendations. Develop clear and concise recommendations for any potential process changes, and present recommendations to the appropriate audience for review and approval.
- Work closely with other areas of the company to ensure effective cooperation and support of medical record retrieval activities.
- Help build an efficient record retrieval and coding process to enhance risk adjustment activities.
- Plan and lead multiple projects and cross-functional teams from inception to completion. This includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring post-implementation issues.
- Reports to a supervisor or manager who provides minimal supervision/project management. Develop own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager.
- Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels.
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Skills / Requirements
Job Reference #: 5548