Overview
Supports clinical activities related to Medicare and Medicaid Risk Adjustment by identifying, collecting, assessing, monitoring, and documenting ICD-10 diagnosis codes in alignment with CMS Hierarchical Condition Categories (HCC). For Medicare, it involves working within a team-based environment to educate providers on coding compliance, enhance clinical documentation accuracy, and improve the quality and completeness of records to support a care model focused on health outcomes. Conducts chart reviews, identifies documentation errors, and alerts leadership to trends or deviations from coding protocols. For Medicaid, the role supports risk adjustment initiatives. Audits and reviews Community Health Assessments (CHA) completed by VNS Health and contracted nurses, provides education based on audit outcomes, and collaborates with various teams to improve the accuracy and completion of CHA assessments.
What We Provide:
- Referral bonus opportunities
- Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
- Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
- Employer-matched retirement saving funds
- Personal and financial wellness programs
- Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
- Generous tuition reimbursement for qualifying degrees
- Opportunities for professional growth and career advancement
- Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
What You Will Do:
- Conducts coding reviews independently on all medical record documentation to assign and/or audit the correct ICD-10 codes and ensure all documentation is accurate, precise, and adherent to CMS guidelines pertinent to Risk Adjustment Hierarchical Condition Category (HCC) methodology. Outreaches supervisor for non-routine issues and new situations.
- Responsible for ensuring completion of medical record reviews and related accurate score based on monthly target set forth by department. * Keeps current on new coding and billing guidelines and federal and state initiatives regarding claims and educates other departments on new/changes to regulations.
- Regulatory Oversight and Quality Assurance and performs medical record compliance audits using the most up-to-date CMS guidelines, output generated is submitted to CMS to accurately capture member's acuity resulting in a compliance and financial impact to the organization, maintains high level of quality and production standards required by leadership to ensure continued medical coding accuracy. This requires advanced knowledge, certifications, and experience related to coding/auditing of ICD 10 Diagnoses based on HCC category.
- Provides audit trail for all identified HCCs in a Medical Record Review through use of audit tool.
- Identifies all unsupported diagnoses/HCCs for all Risk Adjustment Data Validation (RADV) related projects and appropriately notifies management of deficiencies to report to Encounter submissions team.
- Provider Engagement, Audit, Training and Support and supports supervisor in preparing internal presentations, knowledge libraries, coding guidelines, and summary reports of coding review for department infrastructure, maintains professional communication with provider engagement team by assisting with analysis, trending, and presentation of audit/review findings, outcomes, and issues.
- Reports incidental findings, patterns, and trends from audits/coding projects to supervisor thus assisting supervisor in analyzing audit results, tracking and trending. Responsible for supporting supervisor/manager for testing of Coding/Audit tool to ensure appropriate functioning, identifying trends, making recommendations for process improvement for ensuring compliance.
- Enterprise Wide Risk Adjustment Collaboration Activities and Initiatives and support Manager in driving enterprise-wide risk adjustment initiatives. Collaborates internally with Special Investigations and Compliance supporting medical record review and claims analysis for determination of provider engagement in fraud, waste and abuse. Provides guidance to claims team, SIU, and other teams related to ICD 10 Diagnoses codes, CPT and HCPCS codes related to Risk Adjustment in addition to identifying updates for all measures and contract billing codes, as necessary.
- Assists in identifying, developing and implementing Medicaid Risk Adjustment initiatives and activities for ensuring member's acuity aligns with Risk Scores with accurate coding of CHA Assessments.
- Monitors Risk Scores for member's/population, monitoring the dashboards for Utilization and Risk Scores, identifies any deviation in patterns and working leaders and analyst on identifies the root cause and implements an action plan.
- Collaborates with other departments on CHA assessment completion and accuracy.
- Assists in Audit activities of CHA Assessments at a frequency determined as per the workplan.
- Educates and monitors completion of any accompanying action items related to audits, such as trending/tracking of audit scores for improvement, reporting any abnormal findings or patterns to the leadership for development of action items and follow up on action items.
- Identifies ongoing possible discrepancies through review of CHA Assessments and reporting, sharing with assessors and monitoring for corrections if needed on an ongoing basis.
- Collaborates with education department in the development and implementation of Risk Adjustment related training programs.
- Collaborates with Assessment units and other teams to ensure compliance with CMS and DOH standards.
- Keeps informed of the latest internal and external issues and trends in Risk Score activities through networking, professional memberships in related organizations, DOH resources/websites and email updates.
- Assists in development, revisions and updating workflows and policies and procedures related to Risk Adjustment activities.
- Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
Education:
Work Experience:
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Minimum two years of payor work experience with medical records, including ICD-10-CM or current coding system and medical record systems required -
Working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits required -
Additional years of experience/specialized certification/training may be considered in lieu of educational requirements required Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures required -
Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required -
Strong planning, organizational, interpersonal, verbal and written communication skills required -
Knowledge of HIPAA, understanding a commitment to Privacy, Security and Confidentiality of all medical chart documentation required -
Ability to work both in a fast-paced environment and/or be independently self-driven to complete day to day tasks required -
Ability to switch gears and independently collaborate with other departments for all ad lib projects as necessary required.
Pay Range
USD $70,200.00 - USD $87,700.00 /Yr.
About Us
VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us - we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 "neighbors" who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
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VNS Health
paid time off, tuition reimbursement
Jul 21, 2025