HCC Analyst

 

Medica HealthCare Plans, a rapidly growing Managed Healthcare Company located in Coral Gables is seeking an HCC Analyst.

ESSENTIAL DUTIES:Conduct data management. Design and obtain Reports which provides data to use as a basis for selecting Physicians for medical record audits.Obtain reports which cross reference discharge diagnosis coding from inpatient stay billed on the Hospital Claim to diagnosis billed on the Members Physician claims.  This can serve as basis for determining Physicians that are not billed correctly.Design and obtain Reports which provides data on ICD9-CM diagnosis by members that fall in the CMS-HCC risk adjustment model and test for persistency in determining the diagnosis that are expected to be recurring have been submitted at a minimum every 6 months on claims by Physicians – otherwise need to research further.Perform audit of medical records to validate proper coding of claims submitted.  Ensure that diagnosis billed on a claim properly matches what is documented in the medical records.Provide training to Physicians on appropriate medical record documentation and requirement to submit claims for services performed whether or not Physician services are part of capitated services. Provide training to Physicians billing staff/coders on appropriate ICD9-CM diagnosis coding and the importance of coding diagnosis on claims to the highest level of specificity.Work closely with other departments such as Medical Management, Utilization Management on obtaining discharge notes, etc., coordinate with Claims and provider Relations Department for Physician training.  Train Provider Relations Department and possibly other departments on Risk Adjustment coding methodology and requirements.

REQUIRED QUALIFICATIONS:

High School Diploma or equivalent.  Successful completion of medical coding course is required and Certification is preferred.  Experience in Customer Service and/or Managed Healthcare.  Proficient in data base management.

Medica offers a generous compensation package including: Vacation, Medical, Dental, Vision, and 401K.

E-mail resumes to: HR@medicaplans.com   we are a Drug Free Workplace / EOE