Managing Consultant Risk Adjustment Coding Compliance

About BRG Healthcare Analytics

BRG Healthcare Analytics professionals bring extensive industry experience to deliver data driven, independent, and innovative approaches to complex legal, regulatory, and business challenges. Our core strength is the ability to harness and analyze large amounts of electronic healthcare data and turn it into meaningful and insightful information. Healthcare companies trust our independent thinking and ability to solve unstructured problems. We serve a range of healthcare clients including payors, providers, life sciences companies, and the legal and financial firms that work with the industry.

Role Overview

The Coding Compliance Consultant position is a staff consulting position within the Health Analytics Practice (HAP) of BRG. HAP is seeking to add either a Consultant or Managing Consultant to their Coding Compliance team. The work of a Coding Compliance Consultant/Managing Consultant will involve execution of engagement work streams that will primarily involve employing certified coding skills to audit provider claims and provider clinical documentation with a particular focus on ICD-10-CM codes that risk adjust under the CMS-HCC model for Medicare. Responsibilities include working with team to develop audit specifications, expert analysis of healthcare claims and supporting documentation, quality control, and development of client deliverables.

Key Responsibilities

• Apply expertise in medical and risk adjustment coding to conduct coding and documentation quality audits.
• Identify, track, and summarize discrepancies in coding and documentation.
• Use critical thinking skills to evaluate the significance of identified discrepancies.
• Effectively communicate findings and results with team members and clients.
• Stay current on CPT-4/HCPCS and ICD-10-CM coding guidelines, AHA coding clinics, and risk adjustment reimbursement reporting requirements and changes to the CMS-HCC model, as well as current government oversight and enforcement activities around risk adjustment.

Essential Functions

• Audit Planning: Design coding and documentation audit plans for annual and periodic audits and investigations, using knowledge of key risk areas in coding and documentation compliance.
• Conducting Audits and Critiquing External Audits: Perform coding and documentation audits by reviewing medical records and charges to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines and standards, as well as the Centers for Medicare & Medicaid Services (CMS) coverage guidelines. Review results of audits conducted by external parties (e.g., CMS RADV audits) and assist with both identifying records for appeal and drafting narrative appeals.
• Analysis, Reporting, and Education: Conduct analysis of audit findings to identify trends/problems in coding and documentation and recommend areas for improvement. May also lead educational meetings with providers/health plans/legal counsel to review the audit findings.
• Compliance Program Activities: Assist with reviewing, editing, or writing policies and procedures related to billing and coding compliance risk adjustment operations, and provider/coder education trainings.

Additional Responsibilities

• Serve as a subject matter expert on interpretation and application of coding and documentation guidelines.
• Recommend procedural or policy changes to improve coding and documentation practices based on industry knowledge and audit findings.
• Monitor relevant resources, publications, and current government compliance and enforcement activity related to high-risk compliance areas.
• Stay current on coding guidelines, risk adjustment reimbursement requirements, and changes to the CMS-HCC model.
• Generate client deliverables and make valuable contributions to expert reports.
• Manage client relationships and communicate results and work product as appropriate.
• Manage junior staff and delegate assignments as directed by more senior managers.
• Demonstrate creativity and efficient use of relevant software tools and analytical methods to develop solutions.
• Participate in group practice meetings, contribute to business development initiatives and office functions such as staff training and recruiting.
• Prioritize assignments and responsibilities to meet goals and deadlines.
• Comply with HIPAA laws and regulations and all applicable company rules and policies.

Qualifications

• Bachelor Degree in Health Information Management or related healthcare field.
• Minimum of 5 years of risk adjustment coding experience as an auditor/coder within a health plan or medical group/physician office setting.
• Minimum of 3 years of medical coding experience (CPT-4/HCPCS and ICD-10-CM) in a medical group/physician office setting.
• Active certification in medical coding (CPC or CCS-P) through AAPC or AHIMA, as well as active certification as a risk adjustment coder (CRC) through AAPC.
• Preference will be given to candidates who are certified in medical auditing, certified in healthcare compliance, and/or current or former licensed clinicians (e.g., RN).
• Comprehensive knowledge of Medicare rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation.
• Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements, including Physician, Multi-Specialty, Surgical, Hospital, Lab, Pharmacy, or other related Code Sets, with ability to research coding related questions.
• Required skills include: Demonstrated ability to interpret national coding and documentation guidelines and translate them into effective auditing practices and tools; identify issues in coding and documentation practices and develop plans to remediate; develop reports, track, and trend audit findings and results; make timely and appropriate judgements on audit findings and translate into needed actions and follow up plans; and effectively communicate with stakeholders regarding coding and documentation improvement.
• Commitment to producing high quality analysis and attention to detail.
• Excellent verbal/written communication skills.
• Keen interest in healthcare compliance and healthcare policy.
• Excellent time management, attention to detail, follow up skills, organizational skills, and ability to prioritize work and meet deadlines.
• Proficient user in MS office suite: Excel, Outlook, PowerPoint, Word. A desire to expand those capabilities is required, as is the ability to train others to use such tools.
• Candidate must be able to submit verification of their legal right to work in the U.S., without company sponsorship.

Salary Information

Consultant Salary Range: $70,000 – $150,000Managing Consultant Salary Range: $100,000 – $230,000

About BRG

BRG combines world-leading academic credentials with world-tested business expertise and purpose-built emerging technologies. Our culture centers on agility and connectivity which sets us apart and gets you ahead. At BRG, our professionals include specialist consultants, industry experts, renowned academics, and leading-edge data scientists. Together, they bring a diversity of real-world experience, data, and human and artificial intelligence, to economics, disputes, and investigations; corporate finance; and performance improvement services that address the most complex challenges facing organizations across the globe. Our unique structure nurtures the interdisciplinary relationships that give us an edge, laying the groundwork for more informed insights and more original, incisive thinking. When paired with our global reach and resources, our diverse perspectives and technical capabilities make us uniquely capable to address our clients’ challenges. We get results because we know how to apply our thinking to your world. At BRG, we don’t just show you what’s possible. We’re built to help you make it happen. BRG is proud to be an Equal Opportunity Employer. Our hiring practices provide equal opportunity for employment without regard to race, religion, color, sex, gender, national origin, age, United States military veteran status, ancestry, sexual orientation, marital status, family structure, medical condition including genetic characteristics or information, veteran status, or mental or physical disability so long as the essential functions of the job can be performed with or without reasonable accommodation, or any other protected category under federal, state, or local law.

Key skills/competency

• Risk Adjustment Coding
• Compliance Audits
• ICD-10-CM
• CMS-HCC Model
• Provider Documentation
• Healthcare Claims Analysis
• CPT-4/HCPCS
• Medical Auditing
• Healthcare Compliance
• Medicare Regulations