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Purpose:

Responsible for reviewing medical records for Hierarchical Condition Category (HCC) diagnosis codes for focused claims reviews and government audits. Performs auditing functions including monitoring, and coding of HCC diagnosis codes. Reviews medical record documentation, to ensure the HCC diagnosis code(s) are supported within audit year, utilizing AHA Coding clinics, ICD-10-CM Coding Guidelines, and government regulations. Participates in government audits. Assists with the on boarding, and training of new team members. Provides audit and coding related support to the internal Risk Adjustment Department.

Responsibilities:

+ Utilize standard coding guidelines, coding clinics, and government regulations and protocols to verify the appropriate ICD-10-CMS diagnosis code(s) are correctly assigned by internal or external providers, vendors or staff.

+ Ensuring the member's Hierarchical Condition Categories (HCC) 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 regulations, protocols and submission criteria.

+ Understanding of Medicare and Affordable Care Act RADV audits, protocols, guidelines, record submission, audit tools and websites.

+ Assign accurate principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the member's medical records, utilizing knowledge of anatomy, physiology, medical terminology and pathology.

+ Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.

+ Review diagnosis codes submitted by internal/external coders/reviewers and corresponding medical record documentation to ensure the recommended diagnosis code and meets governmental agency requirements for submission.

+ Identify error trends to determine appropriate training needs and suggest modification to policies and procedures.

+ Completion of special projects including focused claims diagnosis codes and/or coding related audit support.

+ Assists Team Lead and/or Manager with research, resolution and response of audit errors, vendor questions, and software implementation/development.

+ Provide training to new Quality Team Members.

+ Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality.

+ Associates degree from an accredited Health information Management program preferred.

+ 3-5 years HCC auditing experience.

+ Graduate of am AHIMA or AAPC Certified Coding program. 5 years of coding experience in a health care setting.

+ Extensive knowledge of ICD-10-CM and CPT classifications and coding of diagnoses and procedures is required.

+ In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.

+ The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential.

+ Excellent written and verbal communication skills are essential.

+ Proficiency in computer skills required for coding (EPIC, Cerner, Clinical Connect, Document Viewer and Internal Risk Adjustment Coding Programs).

+ Detail-oriented individual with excellent organizational skills.High degree of oral and written communication skills. Proficiency in MS Office/PC skills.

+ Traveling may be required as necessary. **Licensure, Certifications, and Clearances:** Cert Professional Coder OR Cert Coding Specialist OR Reg. Health Information Tech OR Reg. Health Information Admin. **UPMC is an Equal Opportunity Employer/Disability/Veteran**