Pay Range:

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Why this job matters:

Perform medical record reviews of Medicare Advantage members to ensure proper medical diagnoses are being submitted to Centers for Medicare & Medicaid Services (CMS) for accurate risk adjustment payments.  Perform data validation of collected medical codes from both outpatient and inpatient settings.  Assist with the review and perform on-site and remote retrieval of medical records for internal and external audits. 

What you will do:

• Perform risk adjustment data validation of Medicare Advantage member charts including outpatient and inpatient services provided by physicians.  Ensure primary and secondary diagnoses are reported in accordance with CMS payment guidelines to ensure Plan receives accurate risk adjustment payments.  Achieve team annual recovery goal targets.

• Coordinate and schedule physician on-site and remote chart reviews with physicians and/or office staff in a professional manner.  Evaluate physician documentation and chart coding to retrieve all primary and secondary diagnosis codes for each member chart. 

• Provide recommendations to physicians to incorporate and promote industry best practices.  Distribute informational/educational correspondence as appropriate.

• Identify errors through data validation; facilitate remediation with internal business areas.  Assist and retrieve member information to correct informational errors as necessary.

• Review claims data to validate member risk scores; gather documentation for CMS appeals if risk scores are challenged. 

• Analyze audit results to and be able to interpret those to leadership to inform coding policies.

• Use NLP (Natural Language Processing) software to audit records, identifying codes to submit for capture and codes eligible for deletion.

• Maintain expert industry knowledge as related to the risk adjuster process and coding regulations.  Actively participate in physician coding review discussions.

• Participate in the retrieval and review of medical documentation relevant to risk adjuster activity for internal and external audits.  Serve as subject matter expert on coding initiatives and member chart review.

• Participate in department initiatives and projects.

• Perform other duties as assigned.

What you need to succeed:

• Certified Professional Coder (CPC, CPC-H), or Certified Coding Specialist (CCS) designation; or an equivalent combination of education and experience

• Three to five years of experience in medical claims review or claims processing

• Three to five years of experience in quantitative or statistical analysis (preferably in health care)

• Proven analytic experience using Microsoft Excel, database query capabilities and ability to evaluate data at various levels of detail

• Proficiency in ICD-9/10-CM medical coding

• Advanced analytical skills, with the ability to interpret and synthesize complex data sets

• Good business acumen and political savvy

• Knowledge of business process improvement techniques and strategies

• Excellent verbal and written communications skills

• Negotiation skills

• Presentation skills

• Decision-making skills

• Good problem-solving skills

• Ability to interface with employees at all levels

• Ability to effectively navigate ambiguous situations with limited direction

• Excellent organizational skills and ability to successfully prioritize multiple tasks

• Ability to handle multiple priorities/projects

The extras:

• Registered Nurse (RN)

• Bachelor’s degree

• Knowledge of ICD-9-CM, ICD-10-CM and CPT coding

• Professional designations (e.g. CPC-H, or CPC-P, CRC)

• Knowledge of Hierarchical Condition Category (HCC) payment model and American Hospital Association Official Coding Guidelines

• Familiarity with hospital contract reimbursement

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia