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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job will deliver value to the Health Plan, and its beneficiaries enrolled in Risk Adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA), using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits. Works closely with physicians, team members, Quality, Compliance, partners at Enterprise and leadership to identify and deliver high quality and accurate risk adjustment coding. Supports all Remote Patient Monitoring (RPM) risk adjustment projects to comply with all CMS requirements by analyzing physician documentation and interpreting into ICD10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of correct Risk Adjustment coding including documentation improvement, provider education, analyzing reports, and identifying process improvements.

ESSENTIAL RESPONSIBILITIES

+ Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark's Policy and Procedures to guide HCC coding decision making. Maintains RPM coding accuracy and productivity requirements.

+ Assists with Regulatory Audits by performing first coding review and ranking of charts. Build partnerships and work within coding teams and internal partners critical to HCC coding.

+ Participates on ad-hoc projects per the direction of Leadership to address the needs of the department. Provides recommendations for process improvements and efficiencies.

+ Engages in RPM Coding educational meetings and annual coding Summit.

+ Other duties as assigned.

EDUCATION

Required

+ None

Substitutions

+ None

Preferred

+ Associate degree in medical billing/coding, health insurance, healthcare or related field preferred.

EXPERIENCE

Required

+ 3 years HCC coding and/or coding and billing

Preferred

+ 5 years HCC coding and/or coding and billing

LICENSES or CERTIFICATIONS

Required (any of the following)

+ Certified Professional Coder (CPC)

+ Certified Risk Coder (CRC)

+ Certified Coding Specialist (CCS)

+ Registered Health Information Technician (RHIT)

Preferred

+ None

SKILLS

+ Critical Thinking

+ Attention to Detail

+ Written and Oral Presentation Skills

+ Written Communications

+ Communication Skills

+ HCC Coding

+ MS Word, Excel, Outlook, PowerPoint

+ Microsoft Office Suite Proficient/ - MS365 & Teams

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Remote Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

_Disclaimer:_ _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._

_Compliance Requirement_ _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._

_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._

_Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._

Pay Range Minimum:

$27.02

Pay Range Maximum:

$41.85

_Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib\_458575\_QLVK9\_1769448333304228022\_1769448333396/1769448333396.pdf)

Req ID: J289847

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Hierarchical Condition Category (HCC) Coding Specialist

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