Job Summary: The Coding, Risk Adjustment and Quality Specialist position supports Montana Health Plus (MTH+) in medical record documentation, coding, risk scoring, and quality measures in the community health centers (CHCs) participating in the MTH+ Clinically Integrated Network/Accountable Care Organization.  The personnel in this position uses their knowledge of documentation guidelines, coding, data, and quality along with clinical skills and practice management knowledge to assist in any and all documentation audits and/or billing functions as determined by the MTH+ team while ensuring that all performance measures are completed annually for the identified patient populations.

Essential Functions (Major Duties or Responsibilities): These duties are the essential functions and are not all-inclusive of all duties that the incumbent performs.

The Coding, Risk Adjustment and Quality Specialist performs analysis on practice risk coding based on information from payers, data, and reports, and creates a stratified plan to work with community health centers that have most opportunity or impact on MTH+ performance in value-based contracts and creating an environment that encourages the highest quality healthcare while simultaneously reducing the total cost of care.

• Completes audits of ICD-10 documentation, coding and billing practices in assigned CHCs
• Provides education and training to office staff and/or providers in proper documentation and coding guidelines as necessary
• Reviews data and reports to identify areas for gaps closure and provides quality documentation to appropriate payer resulting in gap closure for assigned CHCs
• Assists with pre-visit planning and chart scrubbing to ensure care gap closure and accurate code re-capture
• Assists with all MTH+ dashboard and scorecard initiatives to improve performance outcomes
• Queries providers on specificity of coding whenever there is question on specificity level
• Supports the creation of education that will train practice providers, billing, and support staff, as well as MTH+ and MPCA staff, for Medical Risk Adjustment/HCC coding opportunities
• Works in tandem with payers on specific documentation requirements, education materials, and training techniques
• Maintains an audit trail with the results of all medical chart reviews performed, with ability to report on statistics and health center progress on coding initiatives
• Works closely with payers and MTH+ team on supporting special populations and focusing efforts in areas that need improvement. Closely communicating with the payer, the health centers, and MTH+ leadership
• Works collaboratively with the MTH+/MPCA team to ensure alignment of activities to the greatest extent possible and maximize alignment of activities within common members

• Assists in teaching any MTH+/MPCA staff in proper documentation and coding guidelines as necessary

• Reports any issues to supervisor and the MTH+ team as necessary

Qualifications: To achieve high-quality outcomes in primary care the Coding, Risk Adjustment and Quality Specialist is to have knowledge of HEDIS, CMS Hierarchical Condition Category (“HCC”) coding and billing guidelines, STARs measures, clinical standards, outcomes management skills.  In this role, practice level support as well as payer partnerships will be imperative to success.

• High School diploma or equivalent
• Minimum 3-5 years coding experience
• The American Academy of Professional Coders (AAPC) Certified Risk Adjustment Coder (CRC) certification preferred; CPC will be considered with MRA experience
• Risk Adjustment Experience required
• Experience with clinic billing and coding required
• Knowledge of several EHR systems preferred; preferably Athena, eCW, and Epic

• Clinical background preferred
• Strong knowledge of CMS coding guidelines
• PowerPoint skills in preparing and delivering training
• Presentation skills to deliver training to clinical staff (coding staff and providers)
• Exceptional interpersonal, public speaking, and presentation skills. Clear and confident communicator internally and with members/external partners
• Intermediate knowledge of Microsoft Office applications, including Word, Excel and PowerPoint
• Adaptability – Maintaining effectiveness when experiencing major changes in work tasks or the work environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
• Ability to facilitate group discussions that challenge participants to consider various approaches/solutions.
• Managing Conflict – Dealing effectively with others in an antagonistic situation; using appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
• Ability to work independently; resourceful and proactive
• Ability to communicate effectively in writing and verbally with individuals at all levels of health care provision; summarize information and instructions for clarity and understanding
• Analytical, creative and takes innovative approaches to solving problems
• Positive, people-oriented, and energetic attitude
• Ability to work in a rapidly changing and fast-paced environment
• Self-motivated, highly organized, and able to prioritize and manage multiple tasks
• Ability to anticipate and identify ever-changing needs for the practices as they arise
• Passionate about improving the healthcare system

• Fluency in written and spoken English
• Solid knowledge of, and value for, cultural competence and diversity, equality, equity and inclusion.

• Ability to travel to and within the state of Montana
• A valid unrestricted drivers’ license
• Reliable and insured vehicle
• Home office that is HIPAA compliant

Working Environment and Physical Activities

• Remote work from home.
• This position typically requires several hours of travel to meetings in the state of Montana.

The ideal candidate will display sound judgment, relate well to the public and staff, have a professional demeanor, prioritize customer satisfaction, and be well organized.

MTH+ is an equal opportunity employer offering a generous benefits package, a casual work environment, and a competitive salary (DOE).

Category:  Full-Time, Exempt

Responsible to: Director of Montana Health Plus

Supervises:  N/A

Job Description Effective Date:  September 2024

Hiring Range:  $60,000-$80,000

MTH+ is an equal opportunity employer that provides a comprehensive benefits package that includes:

• Insured group health, dental, & vison plans
• 401k retirement plan with an employer contribution match
• Life, AD&D, and Long-term disability plans paid for by employer
• A generous mix of vacation, sick and holiday paid days off

Benefits: 401k Safe Harbor, Health/Dental/Life Insurance, Paid leave