Your Role

The Risk Adjustment Coding & Auditing team conducts various on-going audits to ensure our embers' health conditions are accurately captured and coded. . The Senior Medical Coder Auditor will report to the Manager of Medical Coding Auditing. In this role you will be responsible for prospective and retrospective clinical documentation review with an emphasis on the completeness and accuracy of provider documentation. You will play a vital role in ensuring accurate and compliant coding within our healthcare organization.

Your Work

In this role, you will:

• Perform audit projects, including and not limited to Government RADVs, and internal compliance audits
• Support and implement prospective, retrospective and auditing project strategy to support improved clinical documentation and coding
• Be responsible for facilitating and/or performing an audit of the providers' medical chart to ensure appropriate documentation exists to support the diagnoses submitted appropriately
• Reference inconsistent or incomplete patient treatment information/documentation to coding quality analyst, provider, supervisor or individual department for clarification/additional information for accurate code assignment
• Train physicians and other staff regarding documentation, billing and coding and provides feedback to physicians regarding documentation practices upon request
• Adhere to Blue Shield's standards and policies for coding and compliance
• Work independently and as part of a team to communicate effectively with team members and other departments to resolve coding issues and discrepancies
• Act as a subject matter expert (SME) for other team members and provide guidance on coding-related matters.
• Participate in regular training and education to stay up to date on current coding guidelines, regulations, and industry changes to ensure compliance
• Assist with internal and external coding audits to ensure the quality and compliance of coding practices

Your Knowledge and Experience

• Requires an associate's degree or equivalent experience
• Requires at least 3 years of relevant coding experience with a high-level of coding expertise in the following areas and/or disciplines: Risk Adjustment/HCC Coding, Auditing (Outpatient/Inpatient)
• Requires an acceptable coding certification; CCS/CCS-P or CPC/CPC-H
• Requires a strong ability to lead and/or facilitate meeting with internal and external stakeholders (vendors)
• Requires at least 3 years of project management and/or coordinating detailed projects or activities
• Requires proven success in building relationships and establishing credibility with providers and other clinical staff
• Requires expertise in supporting a CMS Risk Adjustment Data Validation (RADV) Audit for both Medicare Advantage Plans and the Affordable Care Act (ACA).
• Requires strong proficiency with MS word and Excel exposure to utilizing common Electronic Medical Record software (Epic, Allscripts, nextgen, eClinical Works, etc.)
• Requires excellent analytical and problem solving skills

Pay Range:

The pay range for this role is: $ 77990.00 to $ 116930.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.