The Risk Adjustment Auditor I for Baylor Scott and White Health (BSWH) is responsible for reviewing member records to accurately maximize risk scoring in keeping with Scott and White Health Plan (SWHP) risk adjustment strategies and processes for lines of business subject to risk adjustment. He / She is responsible for conducting provider audits and creating/presenting training and education to providers on Risk Adjustment Methodology.
In addition, the Risk Adjustment Auditor I for BSWH has the following responsibilities:
Interpret health record documentation using knowledge of anatomy, physiology, pathological processes of disease, and medical terminology to code and abstract diagnoses and/or procedures for inpatient, outpatient, and clinic cases
Abstract pertinent information from data files and records and is able to accurately transfer or coordinate transfer into the appropriate Health Plan System or Risk Adjustment Software
Evaluate the impact of code selection on the Risk Adjustment assignment to ensure proper level of payment
Conduct focused HCC reviews on providers and clinics, tracking results and identifying trends and deficiencies for follow-up training
Create educational materials for HCC specific methodology and presents training to providers, 1:1 or in groups
Work in collaboration with medical services, provider relations, configuration, claims, medical informatics and information systems staff on assigned projects to identify required coding sets for tracking/trending for data for multi-use reporting purposes
Assist SWHP Provider Audit Committee as needed with provider documentation reviews related to coding on claims to identify potential fraud, waste or abuse related to coding
Independently research complex coding issues and keeps abreast of coding and compliance changes as communicated by CMS, HHS, AHA, AMA and the Federal Register
Abide by the standards of ethical coding as set forth by the American Health Information Management Association (AHIMA)
Comply with official coding rules and guidelines to ensure high quality health information and accurate claims submission
Demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in professional activities
Protect data integrity and validity
Respect patient confidentiality for accessing and disclosure of health information
The ideal candidate will possess the following knowledge, skills and abilities:
Knowledge of ICD-9-CM and CPT coding conventions, and clinical documentation.
HCC experience preferred
Experience providing physician feedback
Group training experience preferred
Ability to pass in-house coding exam with 90% or above
Knowledge of Microsoft Word, Excel, and PowerPoint
One of the following certifications are required: RHIT, RHIA, CPC, COC, CCS, CCS-P, CIC, CFPC, CEMC, CIMC or CRC
Location/Facility - Dallas
For more information on the facility, please click our Locations link.
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it's accepting a calling!
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!