Title: Risk Adjustment Consultant

Hours: 40 hours per week; M-F.

Location: Fully Remote

Job Overview

Under the director of the Director, Risk Adjustment Operations,  performs accurate and timely reviews and validations of Medicare, Medicaid, Commercial HCCs and DxCG’s through medical record reviews. Reviews provider documentation for ICD-10-CM codes to verify that coding meets both established coding standards as well as CMS and Commercial Risk Adjustment guidelines. This position has extensive knowledge of overall ICD-10-CM coding standards, as well as lead efforts to evaluate the HCC/DxCG coding practices and provide analyses and recommendations to improve overall provider documentation as it pertains to coding and risk adjustment guidelines. Reviews medical records to determine if diagnostic codes (ICD-10-CM) as well as Current Procedural Terminology codes (CPT) are accurately reflecting the provider documentation. Summarizes findings for internal and external parties and will provide provider education when necessary.

Job Description

Minimum Qualifications:

1. Certified Risk Adjustment Coder (CRC) OR must obtain within first 12 months of employment

2. Two (2) years of outpatient billing, coding, and risk adjustment experience.

Preferred Qualifications:

1. Associate’s degree.

2. Certified Risk Adjustment Coder (CRC) highly preferred.

3. Two (2)  years of outpatient billing, coding, risk adjustment, and primary care adult medicine experience.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1. Performs ongoing audit of medical records for our LCO groups and network providers to ensure diagnosis and CPT coding accuracy.

2. Performs medical record audits to determine coding accuracy to coding standards in correlation to CMS and DxCG regulations and guidelines.

3. Evaluates medical records for authorized providers, face-to-face CPT codes, and appropriate written and electronic signatures as well as other technical requirements.

4. Summarizes and interprets audit findings for Director Risk Adjustment Operations/NEQCA Leadership; tracks audit results over time, identifies trends, and recommends corrective actions.

5. Collaborates with Director Risk Adjustment Operations/NEQCA staff and vendors to identify and submit coding adjustments, as needed.

6. Provides education and feedback to physicians on a regular basis in regard to Risk Adjustment Coding guidelines (HCC/DxCG), as well as ICD-10-CM Guidelines and regular coding requirements. 

7. Maintains a current and strong understanding of coding rules and CMS guidelines in the outpatient settings.

8. Interprets and summarizes coding guidelines and CMS regulations for TMCPO/NEQCA leadership. 

9. Incorporates changes to guidelines and regulations into audit practice.

10. Researches and resolves coding and risk adjustment regulatory issues.

11. Works retrospective/concurrent audit reports to close diagnosis gaps within our risk adjustment contracts.

12. Performs pre-visit chart reviews and provider outreach.

13. Provides coding expertise to evaluate internal coding program opportunities.

14. Provides LCO and network providers trainings and education as needed.

15. Summarizes and presents recommendations to key internal staff.

16. Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action.

Physical Requirements:

1. Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.

2. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending/descending stairs and operating office equipment.

3. Frequently required to speak, hear, communicate and exchange information.

4. Ability to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.

5. Occasionally lift and/or move up to 25 lbs.

Skills & Abilities:

1. Excellent organizational and interpersonal skills are essential as well as the ability to work on multiple tasks, to work under pressure, meet deadlines and provide excellent follow up. 

2. Excellent Communication skills are essential to give oral presentations to staff as well as written skills to prepare reports for management.

3. Ability to work effectively as a member of a team.

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following Health Information Management duties: Responsible for the accuracy, maintenance, security, and confidentiality of patient's health information. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.   The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.  An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience.   Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range:

based on full-time equivalent