Role Description The Risk Adjustment HCC Quality, Expert is responsible for ensuring all functions of the quality, review, audit, and coding program for the Quality, Risk Adjustment Team are operationally optimized. This position requires a comprehensive understanding of health insurance, risk adjustment, clinical documentation, coding, educational processes and programs, and governmental regulations. This position will take a leadership role in the enhancement and implementation of a full range of quality initiatives, programs, and audits. They will serve as a liaison to internal and external staff, including but not limited to external vendors who provide services related to risk adjustment quality, coding and reviews and external entities which have purchased services from the Health Plan, including a full range of services related to risk adjustment quality, auditing, and coding. The Risk Adjustment HCC Quality Expert will serve as a role model, mentor and resource for quality team members, abstractors, coders and other risk adjustment department staff and management. The Risk Adjustment HCC Quality Expert will work collaboratively with the Quality Manager and Team Lead on Medicare on data and ACA RADV audits, analysis, and vendor relations. They will provide feedback to Risk Adjustment management and work collaboratively and cooperatively with Quality Assurance, Medicare and other Health Plan departments as required. This is a full time position working Monday through Friday daylight hours and will be a remote position. Due to business needs candidates located in the Eastern Standard Time Zone is preferred and will be highly considered. Responsibilities - Perform duties and responsibilities in a fashion that coincides with the service management philosophy of UPMC, including the demonstration of the basics of service excellence towards patients, visitors, staff, peers, physicians, and other departments. - 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 submission criteria. - Expert knowledge of Medicare and Affordable Care Act RADV audits, protocols, guidelines, record submission, audit tools and websites. - Expertly audit and provide accurate review outcome(s) of principal and secondary diagnoses and procedures by thoroughly reviewing all member’s medical records utilizing knowledge of anatomy, physiology, medical terminology, and pathology. - Expertly audit and provide accurate review outcome(s) of diagnosis codes from members discharge summaries, history and physicals, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room. - Completion of special projects including focused claims diagnosis codes and/or coding related audit support. - Communicate effectively with team members, departmental staff, and outside vendors as necessary to address issues and concerns. As requested, assists other departments with coding audits/reviews. - Provide education and audit related feedback to enhance the coding, clinical documentation, and revenue knowledge base of the Quality and Risk Adjustment team. - Assist with orientation and training for new Quality team members. - Ensuring the member's Hierarchical Condition Categories are supported within the member medical records for the specified audit or review period. - Serve as the quality audit liaison to third parties whom the Health Plan contracts with for audit support. - Serve as an expert resource for other health plan departments for questions related to risk adjustment, coding, auditing, and clinical documentation. - Ensure that all quality tools and presentations are current and consistent with ICD-10-CM, AHA coding clinic, national guidelines, and government RADV protocols. - Coordinate, develop and present focused review and government audit summaries to internal and external health plan teams related to risk adjustment, coding, and documentation. - Identify trends and barriers that interfere with correct coding and documentation practices in the physician practice sites, including but not limited to workflow, electronic health records, and clearinghouses. - Collaborate with the different Risk Adjustment teams to troubleshoot issues related to medical record documentation, coding, electronic health records, claim submission, identify potential solutions, and work arounds to maximize revenue. - Maintain a current and in-depth knowledge of CMS guidelines related to risk adjustment, coding, and documentation, as well knowledge of new models of risk adjustment that impact Health Plan revenue. - Analyze medical record documentation and coding through an audit process that identifies incorrect coding, coding lacking supporting documentation and missed opportunities to capture risk adjustment diagnoses and associated revenue. - Identify barriers and coding trends that may increase audit risk and provide education to coders, educators, and quality staff to minimize risk. - Develop audit tools and coding tools and educational offerings for physicians that highlight poor coding and documentation practices that may increase audit risk. - Serve as a role model, mentor and resource for the Quality Team clinical and coding staff, and other risk adjustment staff, including coders, abstractors, and business analysts. - Assist in the management of special projects related to auditing, HCC coding, and documentation. - Collaborate with Quality Assurance, Medicare team and other Health Plan departments as required. - Effectively prioritize and complete all assigned tasks. Qualifications - Bachelor’s Degree in health care management, nursing or related field or an Associate Degree with relevant experience in nursing, coding, coding management, or HCC Risk Adjustment required. - Master’s degree preferred in nursing, health care administration, or education. - 10 years of relevant experience in professional services, including practice management, nursing, clinical audit, coding, or physician education required. - Progressive leadership experience preferred. - Coding certification in two or more of the following will be required: CCS, CCP, CRC, CPC, CPC-P, CPMA, CIC, COC, CDI. - Extensive coding and auditing background. - Extensive knowledge of the internal claims payment system. - Knowledge of coding, audit and RADV methodologies and their application to healthcare and the development of written summaries, processes, or guidelines. - Expert knowledge of coding and documentation requirements including ICD-10-CM, CPT and HCPCS and coding guidelines. - Expert knowledge of medical terminology, anatomy and physiology, pharmacology, and pathology required. - Expert knowledge of payment models related to risk adjustment, including but not limited to CMS HCC (Hierarchical Condition Categories) Risk Adjustment, ACA, and Medicare RADV protocols. - Excellent verbal and written communication skills, analytical skills and organization skills required. - Extensive problem-solving experience is required. - Expert competence in analysis and problem solving, documentation and communication. - Extensive professional presentation experience and the ability to present information in a clear and professional manner required. - Extensive experience participating in government RADV and HCC audits. - Goal-oriented and experienced with development and implementation of strategic action plans. - Expert computer skills in MS Office and Power Point required. - Expert in researching internal health record systems (Excel, Access, Word, Document Viewer, EPIC, McKesson, and HCC Coding Software). Licensure, Certifications, and Clearances - Act 34 UPMC is an Equal Opportunity Employer/Disability/Veteran