Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
Risk Adjustment Coder & Provider Educator
🔍 New York, New York
Summary of Job
Collaborate with the Manager of Risk Adjustment Coding to identify OIG-related topics, then create effective and engaging provider webinars, and specific provider group training sessions. To support the HCC Data Confirmation programs review supplied medical records to determine if diagnosis codes mapping to HCCs meet government (CMS, HHS, State) documentation guidelines. Support the Manager of Risk Adjustment Coding on Vendor by executing quality coding validations to ensure vendors coding accuracy is meeting established service level agreements (SLAs). Identify areas for improvement for the execution of HCC Data Confirmation programs, and enhancing provider education materials to reflect changes in high risk diagnosis codes per regulatory bodies
Responsibilities:
- Ensure all coding practices follow legal requirements and review medical records to confirm submitted diagnosis codes satisfy M.E.A.T./T.A.M.P.E.R. criteria.
- Work closely with the Manager of Risk Adjustment Coding and external vendors to review, assess, and correct diagnosis codes for submissions, ensuring accuracy.
- Collaborate with leadership to bring Vendor work in-house, address coding updates, and support the HCC Data Risk Adjustment Confirmation Program.
- Help to identify diagnosis trends that can improve provider education and strengthen risk adjustment coding.
- Regularly meet with leadership to discuss coding findings and ways for improvement.
- Notify the Manager of Risk Adjustment Coding when corrective action is needed to maintain coding accuracy and compliance. Maintain a 95% or better coding accuracy through routine performance reviews.
- Collaborate with the Manager of Risk Adjustment Coding to identify key topics related to OIG compliance, risk adjustment, and documentation best practices.
- Create and present engaging provider education materials (e.g., PowerPoints, recorded webinars, webinar-associated quiz with rationales, etc.).
- Ensure that all educational content aligns with regulatory requirements and industry best practices.
- Maintain industry coding knowledge, certifications, and coding compliance expertise.
- Assist in other initiatives and projects as needed.
Qualifications:
- Bachelor’s degree in healthcare or a related field
- CPC and CRC certifications required
- CDIP or CCDS certifications preferred
- 3 – 5+ years of experience in medical coding with a particular focus in risk adjustment (Required)
- 2+ years’ experience in provider education (Required)
- Additional experience/specialisted training/certification(s) may be considered in lieu of BS/BA degree (Required)
- Experience with CMS-HCC, HHS (ACA), and Medicaid models (Required)
- Working knowledge of medical terminology and anatomy/physiology (Required)
- Ability to manage time and work efficiently to meet deadlines with minimal supervision (Required)
- Excellent communication skills (verbal, written, presentation, interpersonal) with all levels/types of audiences (Required)
- Ability to comprehend and deliver complex information effectively and efficiently (Required)
- Strong decision-making and problem-solving capabilities (Required)
- Capacity to multi-task at high detail-oriented level (Required)
- Strong working knowledge of MS Office (Word, Excel, PowerPoint, Teams, Access, etc.) (Required)
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.