HEDIS Coding Specialist (Remote Option-NC)

Competitive Compensation & Benefits Package!

Position eligible for –
• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details.

Office Location: Remote Option; Available for any of Partners’ NC locations (or within 40 miles of NC border)

Closing Date: Open Until Filled

Primary Purpose of Position:

The HEDIS Coding Specialist plays a critical role in ensuring accurate and compliant coding, documentation improvement, and adherence to National Committee for Quality Assurance (NCQA) HEDIS measures and risk adjustment requirements. With a background in medical coding and clinical practice, the specialist is responsible for reviewing medical records, identifying appropriate diagnosis codes, and ensuring documentation supports coding accuracy. Additionally, they collaborate with healthcare providers to address incomplete or missing clinical documentation, educate on proper coding practices, and facilitate training sessions as needed. By conducting audits, analyzing data, and communicating with internal and external stakeholders, the specialist helps improve coding accuracy, optimize revenue, and enhance the quality of care delivered to patients. Their meticulous attention to detail, strong analytical skills, and compliance expertise contribute to the organization’s success in meeting HEDIS reporting requirements and achieving quality improvement goals.

Role and Responsibilities:

1. Coding Review: Conduct thorough reviews of medical records to ensure accurate coding and documentation in compliance with National Committee for Quality Assurance (NCQA) HEDIS measures and risk adjustment requirements.

2. Documentation Improvement: Identify opportunities for documentation improvement to support accurate coding and ensure alignment with coding guidelines and regulatory standards.

3. Provider Education: Collaborate with healthcare providers to educate them on proper documentation practices, coding guidelines, and HEDIS measures. Provide guidance and support to facilitate accurate coding and documentation.

4. Auditing: Perform audits to assess coding accuracy and completeness. Identify discrepancies, coding errors, and areas for improvement through audit findings.

5. Risk Adjustment Coding: Apply expertise in risk adjustment coding to accurately capture and report diagnosis codes relevant to Hierarchical Condition Categories, Risk Adjustment and Managed Care Contract reimbursement initiatives.

6. Data Analysis: Analyze coding and documentation data to identify trends, patterns, and opportunities for improvement. Use data-driven insights to develop strategies for enhancing coding accuracy and documentation completeness.

7. Quality Assurance: Ensure compliance with coding and documentation guidelines, regulatory requirements, and organizational standards. Monitor coding practices and documentation processes to maintain quality and integrity.

8. Provider Support: Serve as a resource for healthcare providers, offering guidance, feedback, and assistance with coding-related inquiries, coding challenges, and documentation queries.

9. Training and Development: Develop and deliver training sessions, workshops, or educational materials to healthcare providers and coding staff on coding best practices, documentation requirements, and HEDIS measures.

10. Collaboration: Collaborate with cross-functional teams, including Quality Improvement, Provider Relations, and Data Analytics, to support quality improvement initiatives, address coding-related issues, and achieve organizational goals.

11. Reporting: Generate reports and documentation to track coding accuracy, documentation improvement efforts, and compliance with HEDIS measures. Communicate findings and recommendations to stakeholders as needed.

12. Continuous Learning: Stay abreast of updates, changes, and advancements in coding guidelines, documentation standards, and regulatory requirements. Continuously enhance knowledge and skills through professional development opportunities.

Knowledge, Skills and Abilities:

Knowledge:

1. Medical Coding: Comprehensive understanding of ICD-10-CM, CPT, and HCPCS coding systems, including knowledge of coding conventions, guidelines, and updates.

2. HEDIS Measures: Familiarity with National Committee for Quality Assurance (NCQA) HEDIS measures, specifications, and reporting requirements.

3. Risk Adjustment: Understanding of risk adjustment methodologies and concepts, including Hierarchical Condition Categories (HCCs) and CMS risk adjustment models.

4. Clinical Documentation: Knowledge of clinical documentation standards, terminology, and practices to ensure accurate coding and documentation.

5. Regulatory Compliance: Understanding of healthcare regulations, coding guidelines, and compliance standards related to HEDIS reporting, risk adjustment, and medical coding.

Skills:

1. Coding Proficiency: Strong coding skills with the ability to accurately assign diagnosis and procedure codes based on clinical documentation.

2. Attention to Detail: Meticulous attention to detail to identify coding discrepancies, documentation deficiencies, and coding errors.

3. Analytical Skills: Ability to analyze coding and documentation data, identify trends, and draw insights to support quality improvement initiatives.

4. Communication Skills: Effective communication skills, both verbal and written, to convey coding guidelines, provide feedback to providers, and collaborate with cross-functional teams.

5. Problem-Solving: Strong problem-solving skills to address coding challenges, resolve discrepancies, and implement solutions to improve coding accuracy and documentation completeness.

Abilities:

1. Adaptability: Ability to adapt to changes in coding guidelines, regulatory requirements, and organizational processes related to HEDIS reporting and risk adjustment.

2. Time Management: Effective time management skills to prioritize tasks, meet deadlines, and manage multiple coding projects simultaneously.

3. Collaboration: Ability to collaborate with healthcare providers, coding staff, quality improvement teams, and other stakeholders to achieve coding accuracy and documentation improvement goals.

4. Continuous Learning: Commitment to continuous learning and professional development to stay updated on coding guidelines, HEDIS measures, risk adjustment methodologies, and regulatory changes.

5. Quality Focus: Strong commitment to quality and accuracy in coding and documentation practices to ensure reliable data for HEDIS reporting and support quality improvement efforts.

Education Required:
• Bachelor’s degree in health information management (HIM), Health Information Technology, Medical Coding, Nursing, or related healthcare field; OR
• Associate’s degree in health information management or medical Coding with minimum 3 years of medical coding experience

Experience Required:
• Minimum 2-3 years of experience in medical coding and documentation
• Minimum 1 year of experience with HEDIS measures and reporting
• Experience with risk adjustment methodologies and HCC coding preferred

Technical Skills:
• Proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding systems
• Experience with coding software and audit tools
• Advanced Excel skills for data analysis and reporting

Performance Metrics:
• Demonstrated coding accuracy rate of 95% or higher
• Ability to code minimum of 20-25 charts per day while maintaining quality standards

Education/Experience Preferred:
• Master’s degree in health information management or related field
• 5+ years of medical coding experience
• Previous experience in managed care or health plan environment
• Experience with Epic, Cerner, or other major EHR systems
• Knowledge of Medicare Advantage and Medicaid managed care operations
• Knowledge of SQL or other database query languages preferred

Licensure/Certifications Required:
• Current certification from AHIMA (CCS, RHIA, RHIT) or AAPC (CPC, CRC)
• HEDIS certification or ability to obtain within 6 months of hire