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Company Job Description/Day to Day Duties:

Job Summary

Directly responsible and accountable for performing chart reviews, physician education, and development of tools to ensure that our provider partners are compliant with Risk Adjustment. Provide overall coding expertise as well as administrative and technical oversight to ensure successful integration of Molina Medicare’s Risk Adjustment initiatives. May require some travel to various provider partner locations

• Performs on-going chart reviews and abstracts diagnoses codes under the HCC Model. 

• Develop an understanding of current billing practices in provider offices to ensure that diagnoses codes are submitted accordingly. 

• Documents results/findings from chart reviews and provides feedback to management, providers, and office staff. 

• Responsible for administrative duties such as planning, scheduling of chart reviews, obtaining of medical records, and provider training and education. 

• Monitor HCC Coding Accuracy at various levels of detail (e.g., by state, by product, by demographic segmentations). Extract information necessary to identify where there are low performing physicians; follow up with plan for education and training. Continue to audit to ensure training is implemented. 

• Resolve and track escalated issues. Track any coding issues identified either at the provider level (including Molina sites) or vendor; manage any non-compliance situation or potential fraud or abuse. 

• Utilize discretion and autonomy to select provider for further training or audits; coordinate efforts with internal clients such as Coding Manager, RAMP Director, State Medicare Directors and Provider Services. 

• Determine coding quality as it relates to CMS standards; selects physicians or vendors that require an audit. 

Minimum Education/Qualifications/Licensures:

Coding Certification - Active CCS, CCS-P, or CPC credentialing

Coding guidelines knowledge

Travel required (with mileage)

Claims experience

Employment Type: Contract 6 months. With possibility of going perm.