Location: GeorgiaDepartment: HS-Encounters & RAPSReports to: Mgr, Risk Adj Audit & Prov Ed
Conduct provider medical record audits, analysis of practice coding patterns, education and training regarding risk adjustment to ensure accurate CMS payment and improve quality of care. Analysis of MRA data to identify patterns and development of interventions at the provider and market level.
Subject matter experts for proper risk adjustment coding and CMS data validation
Work in conjunction with other departments to include Provider Relations, Quality as well as the Medical Director for the state assigned to ensure compliance of CMS risk adjustments guidelines are met.
Analyze MRA data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for WellCare contracted providers.
Conduct provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care. This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc.
Works on additional risk adjustment audit requests (i.e. outside auditors' requests).
Serves on the RADV Committee as subject matter experts.
Perform quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-9/ICD-10 coding) for WellCare's Medical Coding Specialists.
Communicates QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics.
Perform other duties as necessary.
Required A High School or GED
Preferred An Associate's Degree in Health Information, Health Administration or other relevant field
Required 5 years of experience in a hospital, a physician setting or a Managed Care Organization as a medical coder
Required 2 years of experience in coding with knowledge of Medicare risk adjustment (HCC Coding)
Required Other experience in teaching, training or an educator/instructor role required; but provider education experience is preferred
Preferred Other managed care experience
Advanced Demonstrated interpersonal/verbal communication skills
Advanced Demonstrated written communication skills
Advanced Ability to represent the company with external constituents
Advanced Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
Advanced Other Proficient in public speaking, presentations, and educational activities
Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
Intermediate Demonstrated written communication skills
Intermediate Demonstrated organizational skills
Intermediate Ability to work as part of a team
Intermediate Ability to work independently
Licenses and Certifications: A license in one of the following is required:
Required Other One of the following certifications are required at the time of hire: CPC or CCS
Required Other CPMA is required within the first year of employment
Required Other CRC required on the second year of employment
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Visio
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.