Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

• Annual incentive bonus plan based on company achievement of goals

• Time away from work including paid holidays, paid time off and volunteer time off

• Professional development courses, mentorship opportunities, and tuition reimbursement program

• Paid parental leave and adoption leave with adoption financial assistance

• Employee discount program

Job Description Summary:

Develops expert knowledge of the Centers for Medicare and Medicaid Services (CMS) Commercial Risk Adjustment and Medicare Advantage Rating models in order to develop best practices for clinical coding programs within our risk adjustment initiatives. In addition to ensuring the accuracy, quality, and integrity of the data gathered and submitted to CMS, this person will perform detailed and complex review of organizational programs in order to evaluate risk score and star measure outcomes and identify improvement opportunities.

Job Description

• Reviews medical record and claims information to identify all appropriate coding based on Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC & HHS-HCC) models

• Provides real time support and coordination visiting Primary Care Providers and Care Coordinators for Commercial Risk Adjustment coding education

• Develops policies and procedures for system, application and related operational processes in order to ensure optimization and compliance with CMS risk adjustment and Star measurement coding guidelines

• Abstract all risk adjusted diagnosis codes from acceptable provider documentation and in accordance with industry standards for coding and reporting.

• Adheres to current industry standard, as defined in the ICD-10 guidelines for coding and reporting.

• Conducts Provider queries for any documentation inconsistencies within client electronic medical record and/or other query system

• Confirms accurate entry of risk adjusted codes into proprietary software or database as defined by project and client scope.

• Must be able to maintain 95% accuracy and completeness in ongoing quality assurance reviews as required by internal QA policy.

• Uses expert knowledge of CMS-HCC & HHS-HCC Risk Adjustment Model to provide support in forecasting care opportunities within Commercial risk adjustment and Medicare Advantage segments, coding of Diagnosis codes that pertain to HCCs

• Provides encounter data reconciliation between CMS and health plan claims detail to ensure accurate risk adjustment payments

• Additional duties as necessary to meet CMS guidelines and regulations

• Develops and shares guidelines/best practices with internal risk adjustment coders to improve coding documentation techniques.

• May develop policies and procedures for system, application and /or related operational processes in order to ensure optimization and compliance with CMS risk adjustment and Star measurement coding guidelines

• May pull medical records for our risk adjustment/HEDIS/STARS projects

• Helps with special projects within our Risk Adjustment Operations group

Minimum Qualifications

• Bachelor’s degree in business administration or Bachelor of Science in Nursing (BSN), health administration, or related field or an equivalent combination of education and experience.

• 3 years of medical coding experience in a healthcare plan or environment

• 2 years of experience working in medical information environment (ex. At health plan, provider office, hospital, etc.)

• CPC (Certified Professional Coder) or Equivalent

• Must obtain CRC within one year of employment

Preferred Qualifications

• 2 years of risk adjustment coding experience

• Experience with MS Excel and MS Project

• Risk Adjustment program experience

• ICD-10 Proficiency

• CRC (Certified Risk Adjustment Coder)

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.