Company Statement

Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions.  WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.

 

To protect the health and safety of our workforce, members, patients, and the communities we serve, the EmblemHealth family of companies require all new employees to be fully vaccinated for COVID-19. Exemption/reasonable accommodations may be granted because of 1) a qualifying medical condition or disability that makes getting the vaccine unsafe for the individual, or 2) objection on the basis of sincerely held religious beliefs and/or practices.
 

Risk Adjustment Coding Specialist

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Manager & Professional
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EmblemHealth
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Support the creation, maintenance, and enhancement of a culture of best-in-class clinical documentation accuracy in support of building a model of care focused on quality and health outcomes. Work closely with Provider Engagement, Clinical, and Compliance teams to leverage clinical, coding, and documentation expertise to foster improvements in the overall quality, completeness, and compliance of clinical documentation. Assist healthcare providers to understand specific documentation topics as well as the issues facing healthcare providers to create buy-in. Alert Medical and Finance leadership of trends and irregularities evidencing deviations from coding protocols. Conduct Chart review around Provider Risk Adjustment Activity and clinical documentation errors around HCC alerts addressed at DOS.

Responsibilities:

  • Serve as the subject matter expert on HCC documentation requirements and ICD-10-CM coding guidelines (CDPS documentation requirement understanding a plus).
  • Conduct coding review on all provider documentation to assign the correct ICD-10 codes and ensure all documentation is accurate, precise, and adherent to CMS guidelines. 
  • Engage with medical practitioners to provide feedback and educational resources on best practices for medical coding.
  • Query providers to ensure that appropriate documentation appears in the medical record. 
  • Maintain log of all documentation audits / reviews and conduct ongoing follow up activities and communication for uncompleted or unanswered queries.
  • Maintain professional communication with provider engagement team by assisting with analysis, trending, and presentation of audit / review findings, outcomes, and issues.
  • May serve as mentor and resource to other staff members and departments.  

Qualifications:

  • Bachelor’s degree
  • CRC Certification
  • 3 - 5 years related work experience (R)
  • 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits (R)
  • Additional years of experience/specialized certification/training may be considered in lieu of educational requirements (R)
  • EPIC EMR experience (R)
  • Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures (R)
  • Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications (R)
  • Strong planning, organizational, interpersonal, verbal and written communication skills (R)
  • Must be PC literate and possess a strong understanding of Microsoft applications (R)
  • Ability to handle multiple priorities and meet deadlines (R) 

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