Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Risk Adjustment Coding Specialist

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Manager & Professional
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EmblemHealth
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Support the creation, maintenance, and enhancement of a culture of best-in-class clinical documentation accuracy in support of building a model of care focused on quality and health outcomes. Work closely with Provider Engagement, Clinical, and Compliance teams to leverage clinical, coding, and documentation expertise to foster improvements in the overall quality, completeness, and compliance of clinical documentation. Assist healthcare providers to understand specific documentation topics as well as the issues facing healthcare providers to create buy-in. Alert Medical and Finance leadership of trends and irregularities evidencing deviations from coding protocols. Conduct Chart review around Provider Risk Adjustment Activity and clinical documentation errors around HCC alerts addressed at DOS.

Responsibilities:

  • Serve as the subject matter expert on HCC documentation requirements and ICD-10-CM coding guidelines (CDPS documentation requirement understanding a plus).
  • Conduct coding review on all provider documentation to assign the correct ICD-10 codes and ensure all documentation is accurate, precise, and adherent to CMS guidelines. 
  • Engage with medical practitioners to provide feedback and educational resources on best practices for medical coding.
  • Query providers to ensure that appropriate documentation appears in the medical record. 
  • Maintain log of all documentation audits / reviews and conduct ongoing follow up activities and communication for uncompleted or unanswered queries.
  • Maintain professional communication with provider engagement team by assisting with analysis, trending, and presentation of audit / review findings, outcomes, and issues.
  • May serve as mentor and resource to other staff members and departments.  

Qualifications:

  • Bachelor’s degree
  • CRC Certification
  • 3 - 5 years related work experience (R)
  • 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits (R)
  • Additional years of experience/specialized certification/training may be considered in lieu of educational requirements (R)
  • EPIC EMR experience (R)
  • Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures (R)
  • Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications (R)
  • Strong planning, organizational, interpersonal, verbal and written communication skills (R)
  • Must be PC literate and possess a strong understanding of Microsoft applications (R)
  • Ability to handle multiple priorities and meet deadlines (R) 

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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