Compliance Consultant V, Medical Coding - Risk Adjustment

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 V, Medical Coding applies advanced knowledge of ICD-10-CM coding, hierarchical condition category methodology, clinical documentation standards, and risk adjustment production workflows to supervise and monitor coding operations.
The Compliance Consultant V, Medical Coding ensures that reported diagnoses are supported by eligible provider documentation, acceptable encounters, applicable dates of service, and valid medical record evidence. This position reviews complex coding scenarios, interprets coding and risk adjustment requirements, approves or escalates coding determinations, and ensures that coding decisions are consistent, documented, traceable, and defensible during internal or external audits. The role requires proficiency with electronic medical records, coding and encoder applications, workflow management systems, production dashboards, quality reporting tools, and audit platforms. The Compliance Consultant V, Medical Coding analyzes operational data to identify performance trends, coding inconsistencies, documentation concerns, system defects, and workflow barriers and implements corrective actions as needed.
 

In addition to the responsibilities listed below, the position is responsible for serving as a compliance subject matter expert related to functions within all settings of care, maintaining compliance with national coding policies and procedures, assisting with coding questions and related topics, and auditing and monitoring the quality of coding assignments across all lines of business. Additionally, this position is responsible for developing and presenting audit result reports to regional staff and senior management and supporting compliance and the Principles of Responsibility (KPs code of conduct).

• Practices self-leadership and promotes learning in others by building relationships with cross-functional stakeholders; communicating information and providing advice to drive projects forward; influencing team members within assigned unit; listening and responding to, seeking, and addressing performance feedback; adapting to competing demands and new responsibilities; providing feedback to others, including upward feedback to leadership and mentoring junior team members; creating and executing plans to capitalize on strengths and develop weaknesses; and adapting to and learning from change, difficulties, and feedback.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promoting adherence to all procedures and policies; developing work plans to meet business priorities and deadlines; determining and carrying out processes and methodologies; coordinating and delegating resources to accomplish organizational goals; partnering internally and externally to make effective business decisions; solving complex problems; escalating issues or risks as appropriate; monitoring progress and results; recognizing and capitalizing on improvement opportunities; and evaluating recommendations made by others.
• Conducts company compliance activities by partnering with internal and external stakeholders; applying established regulations and standards to compliance efforts; designing, developing, and executing strategic compliance initiatives; analyzing regulations and regulatory changes, and their application to operations; and documenting compliance activities.
• Leads compliance reporting efforts by evaluating and summarizing compliance data, audit information, and potential risks and remedies; identifying and reporting key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations) to management; and developing presentations to convey key findings to management and other key stakeholders.
• Leads compliance investigations by coordinating the collection and analysis of quantitative and qualitative data; leading interviews as appropriate; researching key business issues; identifying potential action steps; and evaluating and recommending corrective action plans for substantiated allegations.
• Manages projects or compliance components of larger cross-functional projects by identifying and managing stakeholder contacts; assembling teams based on project needs and team member strengths; developing, analyzing, and managing project plans; negotiating and managing project schedules and resource forecasts; and managing project financials and deliverables.
• Drives regulatory compliance by monitoring and interpreting complex regulatory changes; leading analysis on regulatory impacts; and overseeing the implementation of designated changes.
• Drives the implementation of compliance efforts by identifying compliance requirements; leading the assessment of current state compliance to identify gaps and corrective actions; creating or revising complex compliance standards, policies and procedures, and training; and monitoring ongoing compliance adherence.

• Minimum six (6) years medical coding experience.
• Minimum three (3) years experience in a leadership role with or without direct reports.
• Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum eight (8) 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 Coding Specialist from American Health Information Management Association OR Certified Risk Adjustment Coder from American Academy of Professional Coders OR Certified Professional Coder from American Academy of Professional Coders