Description
Note: While this role is currently remote, we are prioritizing candidates within commuting distance of our Rossford, Dublin, or Brooklyn offices to accommodate a potential future shift to a hybrid schedule.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Job Summary:
Supervises staff, operations, and activities of the Risk Adjustment Retrieval and Coding Quality Department. Acts as a primary liaison between provider groups, medical coding, and chart retrieval teams to communicate appropriate documentation for Risk Adjustment coding. Serves as a Risk Adjustment documentation subject matter expert; delivers applicable Centers for Medicare/Medicaid Services (CMS) and Health and Human Services (HHS) regulatory guidance and expectations to assigned team. Ensures areas of concern with chart documentation are addressed and that quality and productivity metrics are met and/or exceeded. Maintains cross-functional relationships with other departments as well as vendors to assure timely chart collection efforts and accurate documentation guidelines are communicated and facilitated.
Responsibilities:
- Supervises staff that perform medical record retrieval and quality assurance of documentation and/or coding. Documents discrepancies and identifies and suggests documentation and retrieval opportunities. Develops and maintains productivity analysis based on member-chart correlation. Monitors chart retrieval chase activity progress of team and external vendors, provider communication, Secure File Transfer Protocol (SFTP) submissions and user access. Verifies that staff is following the ICD-10CM Official Coding Guidelines, federal and state regulations, and departmental policies, and meeting quality and productivitystandards. Assists with the development of chase lists and special handling for providers. Provides support for CMS/HHS Risk Adjustment Data Validation (RADV) audits.
- Assists in creating, reviewing, modifying, and implementing Risk Adjustment department policies and procedures (P&Ps) to ensure alignment with Organizational and regulatory requirements. Collaborates with Leadership to establish department goals accordingly.
- Facilitates vendor contracts, including Service Level Agreement (SLA) adherence, processing of invoices and internal Corporate Finance Request (CFR) requests. Performs quality review audits of external vendor and shares those results with leadership as needed.
- Attends continuing education classes to maintain coding proficiency and certification requirements. Maintains knowledge of RADV Protocols, AHA Coding Clinic and ICD-10-CM Official Guidelines for Coding and Reporting, and any updates that affect overall coding and documentation requirements.
- Performs interviews and recommends hires, performance management, and training and development of staff.
- Performs other duties as assigned.
Qualifications:
Education and Experience:
- Bachelor's Degree in Healthcare Administration or related field
- Equivalent education and experience directly related to the role may substitute for a degree.
- 7 years progressive experience as a clinical coding and medical record auditing specialist which includes ICD (International Classification of Diseases and Procedures) and CPT (American Medical Association Current Procedural Terminology) coding systems. Medical record retrieval experience a plus.
- Supervisory or leadership experience preferred.
Professional Certification(s):
- One of the following is required:
- CPC (Certified Professional Coder)
- RHIT (Registered Health Information Technician)
- CCS/CCS-P (Certified Coding Specialist/Physician-based)
- Certified Professional Medical Auditor (CPMA) preferred
- CRC (Certified Risk Adjustment Coder) preferred
Technical Skills and Knowledge:
- Advanced proficiency in ICD, CPT, risk adjustment, Hierarchical Condition Category (HCC), inpatient and professional coding.
- In depth knowledge of Risk Adjustment Data Validation (RADV) protocols as they apply to Risk Adjustment Chart Retrieval.
- Strong knowledge of Market Place and Medicare within a managed care insurance industry.
- Knowledge of industry standards around medical documentation retrieval best practices.
- Knowledge of HIPAA and Protected Health Information (PHI) regulations.
- Expert knowledge and understanding of hospital and provider operations as it applies to medical record retrieval and documentation processes. Ability to identify solutions for the provider groups and facilities the Company works with.
- In depth knowledge of Electronic Health Records (EHR) and document management (e.g., OnBase) systems and the ability to apply to the Company's operations.
- Advanced proficiency with Microsoft Office (Outlook, Excel, Word, Access, Power Point) and coding software.
- Advanced proficiency in CMS and other web-site research for coding changes and risk adjustment guidance.
- Ability to communicate status and findings of documentation retrieved to providers and provider's teams.
- Ability to educate and lead staff on large, time-based projects.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
- Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
- On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
- Discounts at many places in and around town, just for being a Medical Mutual team member.
- The opportunity to earn cash rewards for shopping with our customers.
- Business casual attire, including jeans.
Excellent Benefits and Compensation:
- Employee bonus program.
- 401(k) with company match up to 4% and an additional company contribution.
- Health Savings Account with a company matching contribution.
- Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
- Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
- Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
- After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
- Career development programs and classes.
- Mentoring and coaching to help you advance in your career.
- Tuition reimbursement up to $5,250 per year, the IRS maximum.
- Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
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