Compliance Consultant IV - Medical Coding - Risk Adjustment
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AI Summary
The Compliance Consultant IV independently reviews medical records to assign accurate ICD-10-CM codes and hierarchical condition categories while ensuring regulatory compliance. They also serve as a subject matter expert, conducting audits, managing compliance investigations, and supporting strategic compliance initiatives.
Open to candidates residing in any KP authorized state to include CA, OR, WA, CO, GA, VA, HI, MD & D.C.
Please Note: Salary ranges are geographically based, and the posted range reflects the Northern CA region. Lower salary ranges will apply for other labor markets outside of NCAL.
The Compliance Consultant IV, Medical Coding independently reviews inpatient, outpatient, professional, and supplemental medical records to assign supported ICD-10-CM diagnosis codes and applicable hierarchical condition categories. The coder validates that each reported condition is documented by an eligible provider, supported by the medical record, captured from an acceptable encounter, and coded in accordance with official guidelines, regulatory requirements, and organizational policies. The role requires advanced proficiency in risk adjustment coding platforms, electronic medical records, encoder applications, understanding of documentation cues, and production reporting tools. The Senior Coder is expected to resolve complex documentation and coding issues, recognize unsupported or conflicting diagnoses, document coding rationale, and escalate potential compliance concerns. All coding decisions must be defensible, traceable, and suitable for internal review or external audit.
Job Summary:
In addition to the responsibilities listed below, the position is responsible for serving as a compliance subject matter expert related to coding functions within all settings of care, maintaining compliance with national coding policies and procedures, assisting with coding questions and related topics, and auditing all lines of business for coding. Additionally, this position is responsible for assisting with the development of audit result reports to regional staff and senior management and supporting compliance and the Principles of Responsibility (KPs code of conduct).
Essential Responsibilities:
- Practices self-development and promotes learning in others by proactively providing information, resources, advice, and expertise with coworkers and customers; building relationships with cross-functional stakeholders; influencing others through technical explanations and examples; adapting to competing demands and new responsibilities; listening and responding to, seeking, and addressing performance feedback; providing feedback to others; creating and executing plans to capitalize on strengths and develop weaknesses; supporting team collaboration; and adapting to and learning from change, difficulties, and feedback.
- Completes work assignments and supports business-specific projects by applying expertise in subject area; supporting the development of work plans to meet business priorities and deadlines; ensuring team follows all procedures and policies; coordinating resources to accomplish priorities and deadlines; collaborating cross-functionally to make effective business decisions; solving complex problems; escalating high priority issues or risks as appropriate; and recognizing and capitalizing on improvement opportunities.
- Conducts company compliance activities by collaborating with internal and external stakeholders; applying established regulations and standards to compliance efforts; providing insight and recommendations for the design, development, and execution of strategic compliance initiatives; and documenting compliance activities.
- Develops compliance reports by evaluating and summarizing compliance data, audit information, and potential risks and remedies; reporting to management on key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations); and developing draft presentations to convey key findings.
- Conducts compliance investigations by collecting and analyzing quantitative and qualitative data; conducting interviews as appropriate; researching key business issues; identifying potential action steps; and providing input for the creation of corrective action plans for substantiated allegations.
- Assists with and supports the management of projects or compliance components of larger cross-functional projects by coordinating stakeholder contacts; recommending team resources based on project needs and team member strengths; assisting in the development, analysis, and management of project plans; and coordinating project schedules and resource forecasts.
- Assists with ensuring regulatory compliance by monitoring regulatory changes; conducting analysis on regulatory impacts; and supporting the implementation of designated changes.
- Coordinates the implementation of compliance efforts by identifying compliance requirements; assessing the current state of compliance to identify gaps and corrective actions; creating or revising moderately complex compliance standards, policies and procedures, and training; and monitoring ongoing compliance adherence.
Minimum Qualifications:
- Minimum four (4) years medical coding experience.
- Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum six (6) years experience in health care compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field. Additional equivalent work experience in a directly related field may be substituted for the degree requirement.
- Certified Risk Adjustment Coder from American Academy of Professional Coders OR Certified Coding Specialist from American Health Information Management Association OR Certified Professional Coder from American Academy of Professional Coders
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