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The role requires expertise in areas that include performance management/analytics, data exchanges, electronic medical record systems, provider workflow and processes, health information management, risk adjustment operations (particularly on the prospective side), value-based care, ICD-10, CPT and HCPCS coding principles and guidelines, and population health management.
$72,400 - $120,600 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Experience in key areas of healthcare payer or provider operations, CMS Risk Adjustment and HCC coding process and quality including Medicare Star Ratings and HEDIS. This role is responsible for supporting Cigna Medicare Advantage risk adjustment prospective programs, solutions, and performance in aligned operational region serving as a liaison between Markets and Provider Performance Enablement teams, Provider Education, and the Risk Adjustment Operations teams.
$72,400 - $120,600 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Must have thorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting and AHA Coding Clinic; HCPCS/CPT coding systems and CPT Assistant and Coding Clinic for HCPCS guidelines; Medicare Outpatient Prospective Payment System (OPPS), and Ambulatory Payment Classification (APC.
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Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. About Cigna Healthcare. The role will work under the direction of the Senior Manager - National Lead Provider Education to reach overall operational market goals in conjunction with market Provider Performance Enablement teams and the Risk Adjustment Operations team.
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Documentation Integrity, Coding or Health Information Management Certification through AHIMA, AAPC or ACDIS preferred. Function as a Risk Adjustment and Quality SME to support engagement with market and matrix partners and supports in a consultative way to solution for barriers identified impacting participation with Cigna RA prospective programs.
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Serves as a bridge with market teams and risk adjustment for implementation discussions. The Prospective Program Solutions & Performance Advisor works with aligned region supporting prospective risk adjustment initiatives and programs aimed at improving the accuracy and completeness of risk adjustment, advising the market on risk adjustment strategy based on knowledge of Cigna MA's overall Risk Adjustment programs, with a strong focus on alternate prospective programs and bi-directional data exchange initiatives, and overseeing regional and market program performance.
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Serves as strategic advisor for market specific prospective risk adjustment strategy and solutions. Serve as liaison to share updates with markets/PPE team on risk adjustment programs and strategy. Responsible for identifying and influencing adoption of processes to improve the accuracy and completeness of risk adjustment in the aligned markets.
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7+ years of aligned experience with large provider groups and/or health systems in the area of risk adjustment with integration of tools for RA data capture supporting accurate and complete documentation.
$72,400 - $120,600 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Maintain continuing education treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT and HCPCS codes. Correspond with medicare and various insurance companies to facilitate obtaining pertinent data on compliance, authorizations, verifications, progress notes, medical necessity guidelines and precertification and pre-authorization requirements.
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Expertise in CMS Risk Adjustment Data Validation (RADV) for Medicare Advantage Plans, and medical coding, including but not limited to E/M, ICD-10, CPT, and HCC coding preferred. Certified Risk Adjustment Coder (CRC) required; Certified Clinical Documentation Specialist (CCDS) preferred.
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Works closely with Finance to ensure proper billing, accounting, auditing, CPT coding, Medicare/Medicaid billing procedures and protocols are followed. Manages, coordinates and evaluates all elements of laboratory services in assigned specialties of the Laboratory (Hematology, Chemistry, Microbiology, Blood Bank, Phlebotomy, Specimen Processing, Immunology, Pathology etc.
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Develop new procedures related to HCC coding and assist with implementation of systems that impact coding, such as 3M#s Ambulatory Module# Research payer guidelines or regulatory guidelines that impact coding (ICD10 or CPT) and provide education for Ambulatory Coding Department related to those issues, understanding of claim edits, and denials by payers for coding reasons, to help prevent future denials.
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This position ensures that the documentation is in compliance with Medicare/Medicaid billing regulations, and provider documentation guidelines, CPT documentation and CMS coding guidelines.
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MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
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Daily review of charts to determine if pre-certification/pre-authorization or referrals are needed. To ensure procurement of accurate pre-certification authorization/referral for applicable returning and new patients as well as review and completion of accurate, complete patient charts.
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