Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.
Job SummaryUnder the direction of the Risk Adjustment Supervisor/Manager, performs accurate and timely review and validation of Medicare Advantage, Commercial and Medicaid HCCs through medical record reviews. The Risk Adjustment Coding Specialist III reviews provider documentation of ICD-10-CM (including ICD-9-CM) codes to verify that coding meets both established coding standards as well as CMS and ACA Risk Adjustment guidelines. The Coding Specialist III will lead efforts to evaluate the HCC coding practices and provide analyses and recommendations to improve overall provider documentation and coding. The Risk Adjustment Coding Specialist III will review medical records to determine if diagnostic codes (ICD-9/10-CM) are accurately reflecting the provider documentation. The Risk Adjustment Coding Specialist III coder will summarize findings for internal and external parties. The Coding Specialist III will work on a broad range of audit projects including those with high business impact and that require high levels of expertise and risk adjustment coding experience. The Coder III will at times perform quality control (QC) for the work performed by the Coder Specialist I and Coder Specialist II. They will provide guidance on accurate coding standards. The Coder III’s may also conduct coding and documentation training to network providers and their coding staff.
Key Responsibilities/Duties – what you will be doing
- Performs ongoing audit of medical records from coding vendor and network providers to ensure diagnosis coding accuracy.
- Performs medical record audit to determine coding accuracy to coding standards and CMS regulations.
- Evaluates medical records for appropriate written and electronic signatures as well as other technical requirements.
- Collaborates with THP staff and vendors to identify and submit coding adjustments, as needed. Performs HHS-RADV Audits to include preparing chart for Initial Validation Auditor (IVA).
- Evaluates results from IVA and when applicable, provides ICD-10-CM Guideline(s), AHA Coding Clinic and/or CMS Guidelines to support the validity of the ICD-10-CM code assignment.
- Participates in ad hoc coding projects and face-to-face and small groups provider coding review sessions.
- Maintains a current and strong understanding of coding rules and CMS guidelines in both inpatient and outpatient settings. Priority for the Risk Adjustment Coding Specialist III to compliantly interpret and incorporates ICD-10-CM and ICD-9-CM coding guidelines and CMS regulations. Incorporates changes to guidelines and regulations into audit work in a timely manner.
- Researches and resolves coding questions and risk adjustment regulatory issues.
Qualifications – what you need to perform the job
Completion of a formal coding certification program required. Certified Professional Coder (CPC-A, CPC, CPC-H, COC, CIC, or CRC) certification or Certified Coding Specialist (CCS-P or CCS) required. ICD-10-CM coding proficiency and CRC certification required.
7 or more years of coding experience is preferred. Coding experience in a health plan, hospital or physician practice, billing and/or hospital care management environment required. Prior experience with Risk Adjustment coding and auditing preferred (or 5 or more years in risk adjustment coding experience with provider facing role).
Compensation & Total Rewards Overview
As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company’s sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity
Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team’s strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.