HCC Risk Adjustment Specialist

Job Description

The HCC Risk Adjustment Specialist will perform various audits as assigned by management to ensure physician documentation compliance. The Risk Adjustment Specialist will perform provider training sessions as requested by management as needed. Monitors and tracks success of training and clinician feedback through encounter audits and ensure documentation meets requirements for diagnosis assignment, based on official ICD guidelines. The HCC Risk Adjustment Specialist is responsible for training new staff members as requested by management, as well as, being a resource for other team members and management.

Responsibilities

• Abstract pertinent information from assigned medical records using ICD-9-CM, CPT and/or HCPCS codes.
• Provide management with input on provider performance from assigned audits and special projects
• Document detailed chart audit findings including documentation errors; medical record errors; diagnosis errors as well as missed HCC opportunities in applicable audit tools on a daily basis
• Ensure audit tools contain adequate evidence to support audit findings and reviews audit tools for accuracy and completeness.
• Ensure all captured diagnoses is properly documented and supported within progress note according to CMS rules and regulations including but not limited to encounter date, legibility, proper provider signature and member identification requirements.
• Report noncompliance issues detected through auditing.
• Work with Medical Management to provide confidential feedback on special audits on as needed basis
• Adheres to Official Coding Guidelines.
• Research and provide courteous, accurate and timely response to inquires by providers as related to HCC Risk Adjustment projects and reports.
• Assist with reconciliation of invalid diagnosis list supplied by Other Departments
• Serve as a resource for internal and external customers to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines and regulatory requirements
• Work with Health plans to ensure appropriate status information for member is reflected
• Provide one on one provider training and audit sessions as requested by management
• Attendance of additional provider training sessions based on departmental needs
• Assist with chart retrieval from provider office based on departmental needs. This may include some travel with personal vehicle
• Perform various audits and special projects as assigned by management
  
  

Qualifications

Minimum Education: A High School Diploma or Equivalent; BS/BA preferred.

Minimum Experience: Two to five (2 - 5) years experience in healthcare setting preferably related to HCC Risk Adjustment and/or chart auditing.

Req. Certification/Licensure: Must possess and maintain an AAPC or AHIMA certification — CCS, CCS-P, CPC, CPC-H, CPC-P, RHIT, RHIA.

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.