Risk Adjustment Coding Analyst- Quality Dept- Hansen

Prevea Health
medical insurance
United States, Wisconsin, Green Bay
Mar 19, 2025
Risk Adjustment Coding Analyst Come work where we specialize in you! We have nearly 2,000 reasons for you to consider a career with Prevea Health-they're our employees. We're an organization that values kindness, responsibility, inclusivity, wellness and inspiration. At Prevea, we provide continuous education, training and support so every member of the team contributes to our success. Together we are the best place to get care and the best place to give care. Job Summary At Prevea Health the Risk Adjustment Coding Analyst will perform coding reviews of medical record documentation to ensure proper capture of CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement activities. The Risk Adjustment Coding Analyst will also be responsible for education on HCC's as well as working with different insurance contracts to aid in closure requirements. What you will do Complete thorough medical record reviews, identify and assist the provider to update the Active Problem List for accuracy (highest degree of specificity) by transitioning the less/unspecified diagnoses codes to the most accurate diagnosis and appropriate code specificity. Review records prior to scheduled appointments and accurately identify conditions not yet incorporated in the Problem List to address gaps in preventive services and support code transitions for greater specificity and accuracy. Conduct prospective and retrospective coding activities to capture conditions applicable to Medicare Risk Adjustment reimbursement activities while ensuring compliance with coding guidelines. Perform an audit of medical records on a routine basis to identify all appropriate coding based on CMS HCC categories. Set up meetings with providers to review results of audit. Responsible for education to providers, keeping track of trends and identifying areas for improvement. Communicate findings of Risk Adjustment Data Validation (RADV) audits as need. Advise Chief Quality Officer of trends in inappropriate utilization (under and/over) of the HCC process. Perform quality coding reviews for other lines of business as defined. Work with supervisor to clarify issues of concern, process requests and follow-up. Education Qualifications Associate's Degree in healthcare business services, healthcare administration, medical coding or related degree. Required Experience Qualifications 1-3 years 2 years' experience in a healthcare setting. Required 2 years Experience in Hierarchical Condition Categories (HCC) Conditions Preferred Skills and Abilities The nature of the work is extremely repetitive and detailed. Keen attention to detail, strong focus and organizational skills are essential for proficient accuracy and efficient output and to meet scheduled timeframes and goals. Must have the ability to prioritize to meet deadlines . Self starter with the ability to work independently to achieve company goals. Experience performing data analysis and demonstrated ability to present data utilizing a variety of formats. Understanding of Risk Adjustment Models. Familiarity with Medical Record documentation, auditing and coding guidelines. Experience with electronic medical records, EPIC preferred Familiarity with medical insurance claims process required. Basic understanding of ICD-10 codes Licenses and Certifications Certified Risk Adjustment Coder (CRC) certification Upon Hire Required Certified Professional Coder (CPC) certification Upon Hire Preferred Physical Demands Sit - Constantly Stand - Occasionally Walk - Occasionally Drive - Rarely Climb (Stairs/Ladders) - Rarely Bend (Neck) - Frequently Gross Manipulation (Hands/Arms) - Constantly Squat - Rarely Twist/Turn (Neck) - Frequently Twist/Turn(Waist) - Rarely Lift/Carry 0-10 lbs. - Occasionally Lift/Carry 11-25 lbs. - Rarely Push/Pull up to 10 lbs. - Rarely Push/Pull 11-25 lbs. - Rarely Reach (Above shoulder level) - Occasionally Reach (Below shoulder level) - Constantly Simple Grasping (Hands/Arms) - Constantly Fine Manipulation (Hands/Arms) - Constantly Gross Manipulation (Hands/Arms) - Constantly Working Conditions Noise - Occasionally Hearing Requirements Hears Whispers < 3 feet - Constantly Hears Whispers 3-8 feet - Constantly Vision Requirements Color Discrimination - Constantly Near Vision (Correctable to Jaeger 2 or 20/40 binocular) - Constantly Distance Vision (Correctable to Snellen chart 20/40 binocular) - Constantly Prevea is an Equal Employment Opportunity/Affirmative Action employer. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United State and to complete the required employment eligibility document form upon hire. Prevea participates in E-verify. To learn more about E-Verify, including your rights and responsibilities, please visit www.dhs.gov/E-Verify Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled