Consultant / Managing Consultant - Risk Adjustment Coding Compliance

Overview

A leading consultancy is seeking a Consultant / Managing Consultant – Risk Adjustment Coding Compliance to join its Florida office.

The Coding Compliance Consultant position is a staff consulting position within the Health Analytics Practice (HAP) of the firm. HAP is seeking to add either a Consultant or Managing Consultant to their Coding Compliance team.

The firm’s Healthcare Analytics professionals bring extensive industry experience to deliver data driven, independent, and innovative approaches to complex legal, regulatory, and business challenges. The core strength is the ability to harness and analyze large amounts of electronic healthcare data and turn it into meaningful and insightful information. Healthcare companies trust independent thinking and ability to solve unstructured problems. We serve a range of healthcare clients including payors, providers, life sciences companies, and the legal and financial firms that work with the industry.

The work of a Coding Compliance Consultant/Managing Consultant will involve execution of engagement work streams that will primarily involve employing certified coding skills to audit provider claims and provider clinical documentation with a particular focus on ICD-10-CM codes that risk adjust under the CMS-HCC model for Medicare. Responsibilities include working with team to develop audit specifications, expert analysis of healthcare claims and supporting documentation, quality control, and development of client deliverables.

The Coding Compliance Consultant/Managing Consultant will apply expertise in medical and risk adjustment coding to conduct coding and documentation quality audits, including identifying, tracking, and summarizing discrepancies. The Coding Compliance Consultant/Managing Consultant must have the ability to use critical thinking skills to evaluate the significance of identified discrepancies and be able to effectively communicate findings and results with team members and clients. To perform most effectively, the Coding Compliance Consultant must remain current on CPT-4/HCPCS and ICD-10-CM coding guidelines, AHA coding clinics, and risk adjustment reimbursement reporting requirements and changes to the CMS-HCC model, as well as current government oversight and enforcement activities around risk adjustment.

There is a strong preference for the Consultant/Managing Consultant to be based out of the firm’s Tampa, FL office in a hybrid capacity. However, remote candidates will also be considered. Job title and compensation to be determined based on qualifications and experience. 

Key Responsibilities

• Audit Planning: Has the ability to design coding and documentation audit plans for annual and periodic audits and investigations, using knowledge of key risk areas in coding and documentation compliance.
• Conducting Audits and Critiquing External Audits: Performs coding and documentation audits by reviewing medical records and charges to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines and standards, as well as the Centers for Medicare & Medicaid Services (CMS) coverage guidelines. Work will include reviewing the results of audits conducted by external parties (e.g., CMS RADV audits) and assisting with both identifying records for appeal and drafting narrative appeals.
• Analysis, Reporting, and Education: Conducts analysis of audit findings to identify trends/problems in coding and documentation and effectively and recommend areas for improvement. May also lead educational meetings with providers/health plans/legal counsel to review the audit findings.
• Compliance Program Activities: Has the ability to assist with reviewing, editing, or writing policies and procedures related to billing and coding compliance risk adjustment operations, and provider/coder education trainings.

Additional responsibilities

• Serves as a subject matter expert on interpretation and application of coding and documentation guidelines;
• Recommends procedural or policy changes to improve coding and documentation practices based on industry knowledge and audit findings;
• Monitors relevant resources, publications, and current government compliance and enforcement activity related to high-risk compliance areas;
• Stays current on coding guidelines, risk adjustment reimbursement requirements, and changes to the CMS-HCC model;
• Generates client deliverables and make valuable contributions to expert reports;
• Manages client relationships and communicate results and work product as appropriate;
• Manages junior staff and delegate assignments as directed by more senior managers;
• Demonstrates creativity and efficient use of relevant software tools and analytical methods to develop solutions;
• Participates in group practice meetings, contribute to business development initiatives and office functions such as staff training and recruiting;
• Prioritizes assignments and responsibilities to meet goals and deadlines.
• Complies with HIPAA laws and regulations and all applicable company rules and policies.

Skills, Knowledge & Experience

• Bachelor Degree in Health Information Management or related healthcare field.
• Minimum of 5 years of risk adjustment coding experience as an auditor/coder within a health plan or medical group/physician office setting.
• Minimum of 3 years of medical coding experience (CPT-4/HCPCS and ICD-10-CM) in a medical group/physician office setting.
• Active certification in medical coding (CPC or CCS-P) through AAPC or AHIMA, as well as active certification as a risk adjustment coder (CRC) through AAPC.
• Preference will be given to candidates who are certified in medical auditing, certified in healthcare compliance, and/or current or former licensed clinicians (e.g., RN).
• Comprehensive knowledge of Medicare rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation.
• Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements, including Physician, Multi-Specialty, Surgical, Hospital, Lab, Pharmacy, or other related Code Sets, with ability to research coding related questions.

Demonstrated ability to:

• interpret national coding and documentation guidelines and translate them into effective auditing practices and tools;
• identify issues in coding and documentation practices and develop plans to remediate;
• develop reports, track, and trend audit findings and results;
• make timely and appropriate judgements on audit findings and translate into needed actions and follow up plans; and
• effectively communicate with stakeholders regarding coding and documentation improvement.
• Commitment to producing high quality analysis and attention to detail.
• Excellent verbal/written communication skills.
• Keen interest in healthcare compliance and healthcare policy.
• Excellent time management, attention to detail, follow up skills, organizational skills, and ability to prioritize work and meet deadlines.
• Proficient user in MS office suite: Excel, Outlook, PowerPoint, Word. A desire to expand those capabilities is required, as is the ability to train others to use such tools.