Associate Risk Adjust Analyst - Health First Health Plans, Remote in FL Job at Health First
POSITION SUMMARY\:
To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences, and Financial Stewardship by contributing to Health First Health Plans Risk Adjustment activities that support compliance with regulatory and contractual requirements specific to Medical
Advantage Plans. This individual will provide superior quality by performing medical record chart reviews upheld to the financial and quality standards set forth by the Quality CHA team for reimbursement to the Health Plan by Risk Adjusted ICD-10-CM diagnosis codes. The individual will be responsible for daily operations pertaining to Risk Adjustment including but not limited to\: medical record reviews, potential CMS audits and medical record retrieval efforts. This individual will work closely with management to meet communicated individual and departmental goals; deadlines set forth by CMS, and be active and engaged in establishing effective Risk Adjustment processes.
PRIMARY ACCOUNTABILITIES\:
Quality/No Harm\:
1. Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
2. Consistently meet departmental standards including production standards – pertaining to daily/weekly production, accuracy standards – pertaining to diagnoses captured correctly through medical record review, and financial standards – including diagnosis HCC additions and deletions determined by the Quality CHA Auditors.
4. Ensure compliance with CMS regulations maintaining a process for the collection, submission and reconciliation of all data.
5. Monitor and review all communication from federal and state authorities to identify and analyze revisions or new requirements to determine impact to strategy and first-level tactical planning.
6. Maintain accurate historical records and comprehensive documentation of activities ensuring documents are compiled as needed to successfully meet requirements of federal agencies and stored according to established record retention policies. This includes modifications to meets CMS file requirements for submission of Risk Adjustment files.
7. Participate in CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
Customer Experience\:
8. Develop relationships with key individuals (externally and internally) to foster an increased understanding of the Risk Adjustment process.
9. Participate in special projects as requested by management and assist in identifying opportunities for operational improvements consisted with Health First and Risk Adjustment strategic goals.
10. Assist in coordinating and effectively communicating the health plan's position to regulators during all state and federal audits and site visits.
Stewardship\:
11. Assist in process improvements that will maximize risk adjustment factor increases and avoidance of inaccurate MA plan payments. Coordinate reconciliation efforts with contracted vendors.
12. Review of qualified medical records with documentation to include coding of ICD-10-CM codes to validate Risk Adjustment scores in the Medicare Advantage Plans.
13. Ensure financial impact to organization as well as data submitted for Risk adjustment and HEDIS measures is complete, accurate and thorough to mitigate risk of regulatory agency audits.
14. Gain a thorough understanding of the Risk Adjustment payment methodology, submission requirements and their impact to the Health First Health Plans payments
15. Other duties as assigned.
Qualification:
To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences, and Financial Stewardship by contributing to Health First Health Plans Risk Adjustment activities that support compliance with regulatory and contractual requirements specific to Medical
Advantage Plans. This individual will provide superior quality by performing medical record chart reviews upheld to the financial and quality standards set forth by the Quality CHA team for reimbursement to the Health Plan by Risk Adjusted ICD-10-CM diagnosis codes. The individual will be responsible for daily operations pertaining to Risk Adjustment including but not limited to\: medical record reviews, potential CMS audits and medical record retrieval efforts. This individual will work closely with management to meet communicated individual and departmental goals; deadlines set forth by CMS, and be active and engaged in establishing effective Risk Adjustment processes.
PRIMARY ACCOUNTABILITIES\:
Quality/No Harm\:
1. Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
2. Consistently meet departmental standards including production standards – pertaining to daily/weekly production, accuracy standards – pertaining to diagnoses captured correctly through medical record review, and financial standards – including diagnosis HCC additions and deletions determined by the Quality CHA Auditors.
- Requirements met\: Properly meets audit standards and production standards
- Improvement Required\: fails to meet requirements
4. Ensure compliance with CMS regulations maintaining a process for the collection, submission and reconciliation of all data.
5. Monitor and review all communication from federal and state authorities to identify and analyze revisions or new requirements to determine impact to strategy and first-level tactical planning.
6. Maintain accurate historical records and comprehensive documentation of activities ensuring documents are compiled as needed to successfully meet requirements of federal agencies and stored according to established record retention policies. This includes modifications to meets CMS file requirements for submission of Risk Adjustment files.
7. Participate in CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
Customer Experience\:
8. Develop relationships with key individuals (externally and internally) to foster an increased understanding of the Risk Adjustment process.
9. Participate in special projects as requested by management and assist in identifying opportunities for operational improvements consisted with Health First and Risk Adjustment strategic goals.
10. Assist in coordinating and effectively communicating the health plan's position to regulators during all state and federal audits and site visits.
Stewardship\:
11. Assist in process improvements that will maximize risk adjustment factor increases and avoidance of inaccurate MA plan payments. Coordinate reconciliation efforts with contracted vendors.
12. Review of qualified medical records with documentation to include coding of ICD-10-CM codes to validate Risk Adjustment scores in the Medicare Advantage Plans.
13. Ensure financial impact to organization as well as data submitted for Risk adjustment and HEDIS measures is complete, accurate and thorough to mitigate risk of regulatory agency audits.
14. Gain a thorough understanding of the Risk Adjustment payment methodology, submission requirements and their impact to the Health First Health Plans payments
15. Other duties as assigned.
QUALIFICATIONS REQUIRED\:
- Bachelor’s degree in relevant field preferred; or minimum of 1 year of related work experience.
- Certifications required within the first year of employment\:
- Certified Professional Coder (CPC)
- Must be located within Florida
- Professional Academy for Health Management (PAHM)
- Knowledge of Risk Adjustment, CMS HCC Models and/or HEDIS preferred
- Ability to work independently and effectively to meet re quired daily/weekly goals with minimal supervision
- Ability to analyze and interpret medical records
- Proficient computer skills a must, including but not limited to\: Microsoft Office products, spreadsheet manipulation, and basic understanding of Internet
- Ability to handle multiple tasks and meeting deadlines in a fast-paced, often-stressful environment
- Excellent verbal and written communication skills including the ability to interact professionally with all levels of the organization
- Knowledge and understanding of Federal Medicare program, Medicare Advantage Plans, and the medical insurance industry in general
- Ability to read, analyze and interpret professional/legal/medical documents, policies and procedures, government regulations, legislative issues and legal documents
- Requires reliable transportation and willingness to travel locally if needed
- Ability to work flexible and/or long hours at a desk using computers, telephone and a variety of other automated office machines
- Ability to lift up to 15 pounds unassisted, 2-3 times per day
- Ability to enter data using hand/wrist dexterity
- Ability to stand/walk for 6-8 hours at a time
- Ability to work and function in often-stressful environments
- Ability to pursue multiple concurrent tasks in an autonomous work environment in limited time schedules
- Ability to analyze and interpret information quickly and accurately, responding appropriately to complex problems
- Ability to manage and prioritize responsibilities and goals
- Attitude
- Communication
- Teamwork
- Time management
- Work ethic
- Productivity
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