Peyton Resource Group
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USD
65000
YEAR
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HCC Auditor/Coder
Posted: 02/07/2025
2025-02-07
2025-04-22
Job Number: 21547
Pay Rate: 65000
Job Description
Job Title: HCC Auditor
Reports to: Director ACI/Coding
Job Purpose
Under the direction of the management team, the HCC Auditor is responsible for performing concurrent, prospective, and retrospective chart reviews and data validation to improve the department’s RAF score goals and maximize revenue. This position ensures the accuracy of HCC codes captured in the encounter data submission by reviewing and validating electronic medical charts against provider documentation.
The HCC Auditor will also perform physician queries for coding and documentation clarification during the prospective chart review process. The incumbent will assist in identifying and assessing coding opportunities and areas requiring provider educational outreach. Additionally, this role supports the management team in selecting the best medical records for Health Plan chart review audits and/or CMS RADV audits.
Essential Job Duties & Responsibilities
Reports to: Director ACI/Coding
Job Purpose
Under the direction of the management team, the HCC Auditor is responsible for performing concurrent, prospective, and retrospective chart reviews and data validation to improve the department’s RAF score goals and maximize revenue. This position ensures the accuracy of HCC codes captured in the encounter data submission by reviewing and validating electronic medical charts against provider documentation.
The HCC Auditor will also perform physician queries for coding and documentation clarification during the prospective chart review process. The incumbent will assist in identifying and assessing coding opportunities and areas requiring provider educational outreach. Additionally, this role supports the management team in selecting the best medical records for Health Plan chart review audits and/or CMS RADV audits.
Essential Job Duties & Responsibilities
- Conduct prospective and retrospective chart review audits on outpatient medical records to ensure the accuracy and completeness of documentation supporting HCC coding per ICD-10 CM guidelines.
- Review medical records to identify and validate HCC coding accuracy, abstracting data as necessary when not captured in claim submissions during CMS sweep periods.
- Assist in concurrent chart review processes and perform physician queries for coding and documentation clarification in accordance with established policies.
- Maintain a tracking and management tool for assigned medical record review projects.
- Meet and maintain productivity and quality metrics as defined by QA policy.
- Participate in Health Plan RACCR audits and CMS Risk Adjustment Data Validation (RADV) audits as needed.
- Assist management in selecting "best medical records" to validate and support HCC codes.
- Provide post-chart review audit reports as needed.
- Stay up to date with state and federal regulations, as well as ICD-10-CM coding guidelines.
- Attend coding and documentation webinars (e.G., Optum, AHIMA, AAPC) on a regular basis.
- Follow HIPAA protocols and comply with state and federal regulations.
- Perform additional duties or projects as assigned by management.
- Minimum 3 years of coding experience, including at least 1 year of HCC/risk adjustment coding experience within a managed care or healthcare plan environment.
- At least 1 year of auditing experience with extensive knowledge of Medicare HCC coding protocols.
- Prior experience in healthcare coding and auditing of medical charts.
- Ability to work efficiently in a fast-paced, production-focused environment while maintaining high quality.
- Must be able to work independently, follow instructions, and meet deadlines.
- Ability to identify HCC improvement opportunities and provide feedback to physicians on proper clinical documentation, HCC compliance, and coding guidelines.
- High school diploma required;AA or Bachelor's degree in a related field preferred.
- Active certifications through AHIMA and/or AAPC preferred:
- Certified Professional Coder (CPC)
- Certified Coding Specialist (CCS)
- Certified Coding Specialist –Physician (CCS-P)
- Registered Health Information Technician (RHIT)
- Certified Risk Adjustment Coder (CRC)
- Advanced knowledge of ICD-10-CM, CPT, and HCPCS coding, medical terminology, anatomy, physiology, major disease processes, and pharmacology.
- Familiarity with CMS payment and reimbursement methodologies in managed care.
- Strong understanding of CMS risk adjustment/HCC models, coding, and documentation guidelines.
- Ability to interpret clinical documentation, analyze coding guidelines, and apply MEAT (Monitor, Evaluate, Assess, Treat) principles.
- Proficiency in medical chart audits, HCC coding, and CMS RADV audits.
- High level of accuracy, efficiency, and dependability.
- Strong time management, analytical, organizational, and problem-solving skills.
- Ability to prioritize assignments and meet deadlines in a dynamic environment.
- Strong oral and written communication skills, including presentation abilities.
- Ability to work independently with minimal supervision while maintaining confidentiality in compliance with HIPAA regulations.
- Proficiency in Microsoft Outlook, Excel, and PowerPoint.
- Monday –Friday, 8: 00 a.M. –5: 00 p.M., with additional hours as needed.
- Travel may be required to medical offices for educational sessions.
- Standard office setting with regular use of computers, phones, scanners, and filing cabinets.
- Requires talking, hearing, and sitting for extended periods.
- Some filing required, which may involve lifting files, opening filing cabinets, and standing on a stool as necessary.
- Visual acuity, depth perception, and ability to adjust focus required.
- Services Business: Requires experience with job cost accounting and percentage of completion revenue recognition.