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Performs quality assurance auditing of WellCare's Medical Coding Specialists and external vendors that submit risk adjustment data based on medical record reviews. Conducts provider education and training regarding risk adjustment to ensure accurate CMS payment and improve quality of care using analysis of MRA data to identify patterns and development of interventions at the provider and market level. Owns accountability for the CMS Risk Adjustment Data Validation (RADV) auditing process and other outside audits.
Audits external vendors' coding based on medical record reviews.
Acts as the subject matter experts (SME) for proper risk adjustment coding and CMS data validation.
Conducts provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care. Trains venues such as provider offices and hospitals via onsite visits, webinars, conference calls, email correspondence, etc.
Conducts all activities in relation to CMS RADV audits: medical record review, identifies best medical record, submits all necessary paperwork, transmits data to CMS, responds to all inquiries and provides expertise and support during the appeals process.
Works on additional risk adjustment audit requests (i.e. outside auditors' requests).
Researches medical records identified as "deletes" to determine final disposition.
Sits on the Medical Coding Specialists Help Desk with the ability to research coding questions through approved industry publications and to provide expert guidance.
Serves on the RADV Committee as subject matter experts.
Perform other duties as necessary.
Works in conjunction with other departments to include Provider Relations, Quality as well as the Medical Director for the state assigned to ensure compliance of CMS Risk Adjustment guidelines are being met.
Analyzes MRA data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for WellCare contracted providers.
Perform quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-9/ICD-10 coding) for WellCare's Medical Coding Specialists.
Communicates QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics.
Required A Bachelor's Degree in a health related field or finance
Required 3 years of experience in a hospital or physician setting
Required 3 years of experience in coding with knowledge of RAPS
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Demonstrated analytical skills
Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Intermediate Knowledge of healthcare delivery
Intermediate Ability to represent the company with external constituents
Intermediate Demonstrated written communication skills
Intermediate Demonstrated organizational skills
Intermediate Ability to work as part of a team
Intermediate Ability to work independently
Licenses and Certifications: A license in one of the following is required:
Required Certified Professional Coder (CPC)
Preferred Certified Professional Medical Auditor (CPMA) CPC required
Required Intermediate Microsoft Outlook Knowledge in Microsoft Office including Outlook, Word, Excel, Visio, and Power Point
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Visio
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
Required Intermediate Other Knowledge of RAPS and HEDIS