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Job Summary

The ACO Coding Auditor is responsible for reviewing medical records and identifying, collecting, assessing, monitoring, and documenting claims and encountering information as it pertains to Medicare Risk Adjustment. You implement ongoing quality improvement activities to assure the Medicare Risk score meets all requirements and act as a consulting MRA advisor to the practices you support. You review practices for both CMS and Commercial ACO’s for quality compliance.

Essential Duties & Responsibilities

• Performs on-site and remote clinical validation audits and interpretation of medical documentation to capture all Medicare Risk codes in coordination with the physician.

• Provides guidance and consultation to practice team members to drive improved MRA coding proficiency over time.

• Verifies and ensures the accuracy, completeness, specificity, and appropriate coding based on CMS HCC categories.

• Analyzes and translates medical and clinical diagnoses, procedures, and illnesses into Medicare Risk codes.

• Reviews medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries

• Represent the Quality department with tracking open gaps to ensure HEDIS standards are meet as follow but not limited to: Part-D & Medication Adherence, Part-C & Preventive Care measures, Patient Experience and Audit Process

• Engage with practice management team members on applying correct steps into daily process including and no limited to module software on an ongoing basis.

• Support affiliate medical centers to increase uniformity on the generalization of daily process where Quality data is collected.

• Participates in audits and analyzes data to identify trends and improvement opportunities.

• Performs ongoing analysis of medical charts to ensure all codes are reported timely and properly to CMS.

• Ensures compliance with all applicable Federal, State, and/or County laws and regulations related to Medicare coding and documentation guidelines.

• Facilitates education and/or educates providers and office staff on proper CMS Risk Adjustment coding, billing, pay for performance measurements and medical record review criteria.

• Communicates with co-workers, management, and practice staff regarding documentation, claim submission and reimbursement issues.

• Provides support and compliance through effective communication and training/education.

• Participates in departmental and organizational quality management activities.

• Cooperates with other personnel to achieve department objectives and maintain good employee relations, and interdepartmental objectives.

• Attends departmental meetings as required.

• Effectively manage special projects and other tasks as assigned.

• Document and trend findings in identified database.

• Any other duties or responsibilities assigned.

Supervisory Responsibilities

• No supervisory responsibilities.

Critical Results

Productivity attainment >95% Monthly meeting attainment >95% for all completed Audits Executed SF Assessments and Action Plan

Education & Experience

• High School diploma or GED required.

• Required Certified Coder; CPC, CRC, CCS-P, CCS-H, RHIT

• 3+ years of Medicare Risk Adjustment experience

• Experience working in health care and insurance Industry.

Education Requirements

Required/Preferred

Education Level

Discipline

Required

High School

Knowledge, Skills & Proficiencies

• Ability to travel both locally and across the United States.

• Proficient in ICD-10 coding and strong knowledge of ICD-9 and CPT coding.

• Ability to evaluate medical records with attention to detail.

• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.

• Must be a reliable team player committed to working in a quality and customer centric environment. Will require daily interaction in person, on the phone, and via email.

• Superior customer service skills: demonstrate responsiveness, depth of knowledge and thoroughness in handling and responding to inquiries from patients and team members.

• Base knowledge of clinical standards of care and preventive health standards

• Strong organizational skills and ability to work both independently and with teams.

• Ability to make formal presentations in front of committee and work group environments as needed.

• Ability to use databases and prepare reports as needed.

• Proficiency in Microsoft Word, Microsoft Excel, Microsoft PowerPoint

• Excellent verbal and written communication skills

Physical Requirements

This position works under usual office conditions. The associate is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk, and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include the ability to lift to 50 lbs.

The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing

Travel Requirements

Amount of Expected Travel

Details

Yes

0-25%

Work may involve some driving/traveling to assigned clinics.

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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