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Department:  Business Services
Status:  Full Time
Shift:  1st

Job Summary

Lead all Medicare Advantage Risk Adjustment coding initiatives including prospective chart review and prep, retrospective chart review and audit, and provider education. Manager will coordinate with operations leaders and physicians to ensure HCC and diagnosis coding are complete and accurate.

Oversight of E/M audits and education for Hoag Clinic providers. Manager will coordinate auditing and compliance of use of E/M codes.  Manager will coordinate audits and provider education.

Creation of coding guidelines, best practices training materials, and policies and procedures as it relates to the ICD-10 guidelines and other applicable coding guidelines. Responsible for quality control over internal coder and vendor production.


Job Knowledge, Skills, and Competencies

Critical Thinking - Actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication.

Data Analysis - Identifying, evaluating, interpreting and organizing data so that it can be used for business decisions. It includes sorting through data to identify patterns and establish relationships.

Diversity - Ability to work with a diverse group of people in a manner that enables them to reach their full potential, in pursuit of organizational objectives, without anyone being advantaged or disadvantaged by irrelevant considerations.

Equipment Knowledge – Knowledge of equipment, tools, technology and other devices in work area and the ability to use them to the extent required for the job. For clinical position this includes equipment and devices pertinent to treatment, procedures and practice.

Interpersonal Skills - Listens to and understands what others are saying. Establishes effective working relationships with others, contributing to a climate of mutual respect and cooperation. Uses vocabulary and grammar appropriate to the situation. Demonstrates sensitivity and tact, understanding own effect on the motivation, attitudes and actions of others. Makes favorable first impressions. 

Job Knowledge - The knowledge and understanding of concepts and procedures needed to be successful in the job. For clinical positions, this includes clinical procedures required by department and unit, as demonstrated by unit based competency testing.

Operational Management - the management of the people, resources, deliverables, budgets, general administration and other components of day-to-day management of a functional unit or department.

Oral/Written Communication - Ability to speak and write effectively, demonstrates fundamental command of language, communicates well using all mediums.

Travel – Position may require local travel between various Organization locations.



Education and Experience

  • Bachelor’s Degree in finance, economics, health administration, business administration or related field required; Masters’ Degree preferred
  • Credentials to include one or a combination of the following: RHIA, RHIT CCS and/or CPC
  • Minimum five years of risk adjustment coding experience and professional billing experience; minimum three years’ experience supervising coding staff and programs
  • Previous auditing of clinical data in physician offices or medical facility
  • Knowledge of health care insurance claims practice and compliance.
  • Extensive knowledge of Medicare and CMS Risk Adjustment payment rules, regulations and guidelines as it relates to managed care organizations
  • Knowledge of CPT, ICD-9, ICD-10, DRG, APC/ASC, HEDIS, AAPCC, Medicare services and reimbursement methodologies, revenue codes and RBRVS.
  • Knowledge of risk adjustment categories and hierarchy
  • Knowledge and expertise in E/M code leveling
  • Experience with EPIC EMR


Certifications Preferred

  • Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC)

Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Medical Coding, Medicare, QC, Data Analyst, Manager, Healthcare, Data, Quality, Management

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