This link will leave wellcare.com, opening in a new window. WellCare and its subsidiaries are not responsible for non-WellCare content, privacy practices, products or services described on these websites.
The Provider Coding Educator is responsible for providing Coding Education related to Coding/Documentation Guidelines and Risk Adjustment to our contracted Providers.
Assist in the development of educational materials, policies and procedures, training programs and educational tools for coding staff, Provider Relations and outside physician offices.
Perform quality reviews of medical record documentation to identify opportunities.
Participate in the development and delivery of provider educational materials related to compliant coding and risk adjustment practices.
Provide coding feedback and trends to leadership.
Work collaboratively with internal business partners to enhance provider relationships
Conduct group coding education sessions.
Assist internal coding team as needed with various projects.
Work collaboratively with internal business partners to enhance provider relationships.
Will be relied on as coding subject matter expert of the organization, and will represent the organization in dealing with vendors, delegated entities, providers and the Centers for Medicare and Medicaid Services (CMS).
Collaborate with internal departments to conduct an annual risk adjustment readiness assessment including an analysis of readiness for a CMS risk adjustment data validation audit and provide recommendations to management for strengthening the RPM program.
Participate in risk adjustment data validation audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and conduct medical record chart reviews to validate diagnoses. Perform claims and medical record reviews with focus on accuracy of diagnoses, as needed to respond to particular issues, as part of regulatory audit, or as element of oversight audit.
Maintain knowledge of risk adjustment regulatory requirements and serve as an internal resource for departments in implementing coding and process changes needed to meet compliance.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Preferred A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
Required 2 years of experience in coding using ICD-9/ICD-10, CPT-4 and HCPCS.
Required 1 year of experience in Managed Care experience
Required Other Experience developing and implementing policies and procedures to maintain CMS compliance
Preferred Other Experience with CMS Medicare Advantage Risk Adjustment Data Validation audits, CMS Star rating programs and HEDIS
Preferred Other Experience directly related to record collection with analytical review/evaluation and or Quality Improvement
Intermediate Other Exceptional industry knowledge of Medicare Advantage and "best in class" Quality Improvement programs, processes, procedures, principals and tools with significant experience in performance improvement, quality management, process design, change initiatives.
Intermediate Other Proven experience determining key business issues, developing effective action plans and implementing interventions to bring about successful conclusions.
Intermediate Other Proven experience determining key business issues, developing effective action plans and implementing interventions to bring about successful conclusions
Intermediate Other Proven background developing actionable reports to drive improvement in the organizations performance.
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to implement process improvements
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to influence internal and external constituents
Intermediate Demonstrated analytical skills
Intermediate Demonstrated customer service skills
Intermediate Demonstrated organizational skills
Intermediate Ability to multi-task Exceptional industry knowledge of Medicare Advantage and "best in class" Quality Improvement programs, processes, procedures, principals and tools with significant experience in performance improvement, quality management, process design, change initiatives.
Intermediate Knowledge of healthcare delivery
Licenses and Certifications: A license in one of the following is required:
Required Other AHIMA or AAPC coding certification
Preferred Other One of the following licenses preferred: LPN, LVN, RN, LCSW, LMHC, LMSW, LMFT, APRN, ACNP-BC, HCQM, CHP, CPHQ