American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors residing in long-term care facilities. These Medicare Advantage plans partner with nursing home operators to manage medical risk by improving patient care, reducing emergency room visits, and avoiding hospitalizations.
The Medicare Risk Adjustment Coding Specialist conducts coding audits prior to payment release and performs post-payment coding reviews with overpayments, sending coding education to applicable providers.
Essential duties include reviewing medical records and various reports to verify diagnosis code accuracy based on services rendered, assisting with validation audits to ensure proper coding for CMS reimbursement, interpreting medical documentation for CMS Hierarchical Condition Categories (HCC), developing tools to improve coding accuracy, providing high-level customer service, escalating audit issues when necessary, supporting ad-hoc audits and RADV Audit risk minimization programs, completing assigned coding projects, and other duties.
Requirements include maintaining familiarity with CMS regulations affecting risk adjustment, following federal/state regulations and company policies, maintaining production and quality standards, knowledge of CMS claims processing and coding especially for skilled nursing and complex claims, extensive ICD-9 and ICD-10 coding and auditing knowledge, strong interpersonal and communication skills, organizational skills, confidentiality, analytical skills, ability to work remotely without supervision, and handling multiple priorities.
Qualifications: High school or equivalent; at least 2 years of experience in complex claims processing or coding auditing in health insurance or healthcare delivery, managed healthcare experience related to claims/coding audits, experience with CPT4, ICD10, HCPCS coding and CMS requirements; significant HCC experience including mapping and hierarchy; coding certification (CPC or CRC) required; travel may be required.
This is a remote, full-time position based in Franklin, Tennessee, with no salary specified. Benefits include medical/dental/vision insurance options, generous paid time-off and holidays, TeleDoc 24/7 access, optional disability plans, Employee Assistance Plan, 401K with company match, and employee referral bonuses.
- Maintain high familiarity with current CMS regulations and risk adjustment announcements
- Follow all federal/state regulatory requirements and company policies
- Maintain production and quality standards
- Knowledge of CMS claims processing and coding, skilled nursing and complex claims rules
- Knowledge of coding/auditing claims for Medicare and Medicaid plans
- Extensive ICD-9 & ICD-10 diagnostic coding and auditing knowledge
- Strong interpersonal, written, verbal communication, and organizational skills
- Maintain confidentiality
- Strong analytical and critical thinking skills
- Ability to work remotely without direct supervision
- Successful completion of required training
- Ability to handle multiple priorities
Qualifications:
- High school diploma or equivalent
- 2+ years experience in complex claims processing and/or coding auditing in health insurance or healthcare delivery
- 2+ years experience in managed healthcare environment related to claims and/or coding audits
- 2+ years experience with CPT4, ICD10, HCPCS coding and CMS requirements
- Significant HCC experience including knowledge of HCC mapping and hierarchy
- Coding certification required (CPC or CRC)
- Travel may be required
- Affordable Medical, Dental, and Vision insurance options
- Generous paid time off and paid holidays for full-time staff
- TeleDoc 24/7/365 access to doctors
- Optional short- and long-term disability plans
- Employee Assistance Plan (EAP)
- 401K retirement accounts with company match
- Employee Referral Bonus Program
Location
Tennessee, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
Yes
Posted
3 weeks ago