Risk Adjustment Clinical Auditor/Analyst

UPMC Health Plan has an exciting opportunity for a Risk Adjustment Clinical Auditor/Analyst position in the Medicare department. This is a full time position working Monday through Friday daylight hours and will be fully remote.. The Clinical Auditor/Analyst is an integral part of the Risk Adjustment Department and is responsible for reviewing and auditing medical records for Hierarchical Condition Category (HCC) diagnosis codes for focused claims reviews and government audits. Performs medical records reviews, and auditing functions including monitoring, reviewing, and researching ICD-10-CM diagnosis codes and CPT Codes. Ensure HCC diagnosis code(s) are supported within the audit year, and utilize AHA Coding clinics, ICD-10-CM Coding Guidelines, CPT Coding Guidelines, and government regulations. Participate in government audits conducting research of internal systems and abstracted records of member's selected for audit. Responsibilities:

• Utilize standard coding guidelines and principles, coding clinics, government regulations and protocols to verify the appropriate ICD-10-CM diagnosis code are correctly assigned by internal or external providers, vendors or staff.
• Ensuring the member's HCC(s) are supported within the member medical records for the specified audit period or review time frame.
• Participate in government Risk Adjustment Data Validation audits (RADV) conducting research of internal systems verifying member HCC(s) selected for audit meet ICD-10-CM, AHA coding clinics and government submission criteria.
• Knowledge of Medicare and Affordable Care Act RADV audits, protocols, guidelines, record submission, audit tools and websites.
• Review and analyze medical records utilizing their knowledge of anatomy, physiology, medical terminology and pathology and associated clinical processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules. Accurately review the assigned HCC diagnosis codes and apply the appropriate inpatient or outpatient coding guidelines, AHA coding clinics, ICD-10-CM or government regulations.
• Review provider coding/billing trends, and government audit outcomes to identified HCC coding improvement and opportunities.
• Work in collaboration with appropriate Health Plan departments including Quality Assurance, Medicare, and the Fraud, Waste team to facilitate the resolution of coding issues, focused review outcomes, government audit outcomes, or ad hoc reviews.
• Provide a clinical opinion for special projects or various issues including appropriate diagnosis coding, provider coding trends or identify area's of provider documentation improvements.
• Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality.
• Participate in training programs to develop a thorough understanding of the materials presented. Obtain CPE or CEU's to maintain nursing license, and/or professional designations.
• Within 6 months of hire complete the AAPC CPC certification course and sit and pass the CPC certification exam.
• Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to ensure the accurate assignment of diagnosis and / or procedure codes.
• Communicate effectively with team members, departmental staff and outside vendors as necessary to address issues and concerns.
• Registered Nurse (RN), or Bachelor of Science in Nursing (BSN).
• Five years of clinical experience.
• Two years of either HCC coding, reviews or education, DRG experience, Clinical Documentation Improvement, Fraud & Abuse, Chart Auditing, or Quality Review experience required.
• Ability to analyze diagnosis codes, maintain designated production standards, and organize multiple projects and tasks.
• In-depth knowledge of medical terminology,ICD-10-CM and CPT-4 coding. Knowledge of health insurance products and various lines of business.
• Detail- oriented individual with excellent organizational skills.
• Keyboard dexterity and accuracy.
• High level of oral and written communication skills.
• Proficiency with Microsoft Office products (Excel, Access, and Word).

Licensure, Certifications, and Clearances: CPC Designation preferred.

• Registered Nurse (RN)
• Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

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