Medical Coder, Risk Adjustment Programs

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

 * Please note:  THIS IS A CODE EVERYTHING ROLE - You must have strong proficiency using a coding book, this is not an HCC coding role. 

Job Summary:

The Coder manages the day to day responsibilities of chart abstraction and reporting in accordance with state and federal regulations.  The coder will abstract from inpatient and outpatient medical records and record findings via electronic data base and/or excel spread sheets. The coder ensures that all claims accurately reflect the appropriate diagnosis information as outlined in the member’s medial record. The coder will respond to interdepartmental and provider inquiries guaranteeing that all work is in compliance with internal protocols and external compliance requirements.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation.
• Document coding review may lead to the addition, deletion, adjustment, or confirmation of diagnoses.
• Maintain current knowledge of ICD-10-CM codes, CMS documentation requirements, and state and federal regulations.
• Ensure accurate coding for Medicaid members using the DxCG and CDPS risk models.
• Ensure accurate coding for Medicare members across all models including RADV audits.
• Assist coding leadership by making recommendations for process improvements to further enhance coding quality goals and outcomes.
• Handle other related duties as required or assigned, including Provider Training and working with vendor partners.
• Coders assist with code abstraction and coding quality audits using the Official Coding Guidelines for ICD-10-CM, AHA Coding Clinic Guidance, and in accordance with all state regulations, federal regulations, internal policies, and internal procedures.

Supervision Exercised:

• None

Supervision Received:  

• General supervision is received weekly

Qualifications:

Education:

• Completion of an accredited medical coding program with current certification.
• CPC is  mandatory
• CRC in addition is helpful

Experience Required:

• Minimum of 5 years coding experience with 3 years Risk Adjustment coding/auditing

Experience Preferred/Desirable:

• Risk Adjustment, Provider Training and RADV work.
• Massachusetts’s Medicaid DxCG risk model experience.
• HCC coding experience
• CDPS risk model experience.

Certification or Conditions of Employment:

• Pre-employment background check
• Pre-employment certification check

Competencies, Skills, and Attributes: 

• Strong analytical and problem solving skills.

• Strong oral and written communication skills
• Strong organization and time management skills
• Ability to work independently in a remote home based environment
• Experience with standard Microsoft Office applications, particularly MS Excel and MS Word
• Ability to multi-task

Working Conditions and Physical Effort:

• Fast paced office environment.
• Requires extended periods of time at a computer terminal.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees