Job Description

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

LEVEL 1

  • 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.

     

    LEVEL 2

  • 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.

    ALL LEVELS

  • 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

Required Work Experience 3years of experience working for a healthcare organization / health insurer (All Levels) 2 years of HCC experience performing retrospective risk adjustment chart reviewRequired Education High-School Diploma or GED in general field of study (All Levels)Required Certifications Professional Coder Certification Exam, along with completion of the medical field experience requirement, resulting in certification from a professional coding institute/organization. (All Levels)Preferred Work Experience 5 years of experience working for a healthcare organization / health insurer 3years of HCC experience performing retrospective risk adjustment chart review   2 Years ICD-9 CM/ ICD-10 CM coding experience preferredPreferred Education Associate’s or Bachelor’s Degree in health care related field of study.Preferred Licenses Certified Risk Adjustment Coder (CRC)Required Job Skills (All Levels) Intermediate skill in use of office equipment, including copiers, fax machines, scanners and telephones Intermediate PC proficiency Intermediate proficiency in spreadsheet and word processing softwareRequired Professional Competencies  (All Levels) Strong understanding of the HCC concepts and coding documentation guidelines, as well as impact on Population Health Risk Adjustment reimbursement initiatives Broad understanding of health insurance terms and concepts General knowledge of the healthcare industry Knowledge of coding principles and code sets including UB92, CPT, HCPCS , ICD 9/10, ADA, and ASA Ability to deal with ambiguity and make recommendations with less than complete or conflicting information while maintaining appropriate time management Knowledge of HIPAA recognizing a commitment to privacy, security and confidentiality of all medical charts Ability to communicate effectively, both orally and in writing, to peers, management, providers, and auditors Ability to build and maintain productive working relationships with others Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints Ability to adapt to various coding technology platforms, such as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems Proactive about requesting enough information to fully understand and meet the business needPreferred Job Skills (All Levels) Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones Knowledge of BCBSAZ corporate structure, functions, and procedures Advanced proficiency in spreadsheet and word processing software In-Depth knowledge of BCBSAZ products, processing systems, files, and computer softwarePreferred Professional Competencies  (All Levels) Strong skills in medical record audit and review, and regulatory requirements for coded data. Ability to communicate effectively, both orally and in writing, to all levels in all departments Project management skill needed to create timelines, track deliverables and progress, resolve issues, and communicate project status

Application Instructions

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