General Purpose: The individual holding this position is required to support and demonstrate their commitment to the Longevity Health Statement of Purpose, which is: To improve the health and quality of life of nursing home residents by caring for their unique medical, social and emotional needs.

The Risk Adjustment Clinical Auditor and Documentation Specialist is responsible for conducting retrospective and concurrent medical reviews to ensure the medical record is compliant both in HEDIS Measures, Risk Adjustment documentation standards and code capture according to the national guidelines.

This position can be remote, administrative in function and supports a significant component of Longevity’s Risk Adjustment Program Performance.

 

Key Tasks and Responsibilities:

  • Conduct concurrent medical record and claims review to access medical record documentation practices and accuracy/sufficiency of policies and procedures. Verifies accuracy/appropriateness of submitted diagnosis codes based on medical record documentation looking at both ways 1) appropriate detail in the medical record is not captured in what is reported, and 2) when reported information is not supported by details in the medical record.
  • Provide feedback to Director of Risk Adjustment and Chief Clinical Officer on performance improvement opportunities tracks and prioritizes projects to improve coding and documentation outcomes.
  • Develop and implement action plans to address issues identified through data analysis.
  • Assist with the Development of training programs and tools.
  • Perform internal process and policy audits.
  • Conduct on-going review, monitoring and communications to promote and ensure adherence to established protocols and best practices.
  • Review documentation of well visits (annual well visits and other routine and preventative visits) including the use of appropriate modifiers for telehealth visits, HEDIS scoring accuracy, etc.
  • Monitor internal reporting for coding/CPT outliers, stays up to date with CMS audit processes and actively participates in all audits as they relate to risk adjustment.
  • Make daily decisions and use judgement and critical thinking skills to evaluate level of significance of variances in documentation and coding and based on the review, escalates the variances found to the provider and their supervisors.
  • Appropriately translate national documentation and coding guidelines into effective auditing practices and review/learning tools.
  • Assist Risk Adjustment Director with CMS RADV activities, including suggested record selections tracking and submission, in conjunction with CMS requirements.
  • Perform other related duties as assigned.

 

Licensure:

  • Ongoing AAPC Certified Coder required.
    • AAPC certification(s): CPC or COC plus CRC, CPMA, and/or CDEO.
  • CDIP certification required within 18 months of employment.

 

Education and Training:

  • AS/AA Degree preferred.

 

Knowledge, Skills, and Experience:

  • The Risk Adjustment Clinical Auditor and Documentation Specialist will utilize their knowledge of risk adjustment and professional coding to audit providers’ clinical documentation to ensure accuracy and capture of correct diagnosis codes.
  • Must demonstrate ability to communicate effectively and in a timely manner.
  • Organizational, analytical, verbal, and written communication skills required.
  • Must be able to work well and interact with others in a positive & professional manner when under stressful situations; maintain confidentiality within the work environment.
  • Self-starter with ability to complete responsibilities independently with little supervision.
  • Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks. Stay current of industry coding, compliance, and HCC models.
  • Contribute to team effort by accomplishing related task as assigned to meet the organization’s needs.
  • Professional Coding experience required.
  • 3 to 5 years of risk adjustment coding in a health plan or medical group setting required.
  • Medicare Risk Adjustment Documentation and Coding Auditor experience required.
  • Risk Adjustment Training background preferred.
  • Proficient user in MS office suite: Excel, Outlook, Word, PowerPoint.
  • Demonstrated, excellent critical thinking, decision making skill relative to documentation and coding auditing functions.
  • Effective communication skills (written and verbal).
  • Demonstrated ability to identify issues in documentation and coding practices for risk and/or HEDIS measures and develop plan to remediate.
  • Organized, able to plan and complete work in targeted timeframe.
  • Demonstrated ability to develop reports, track and trend results.
  • Demonstrated ability to interpret national documentation and coding guidelines and translate them into effective auditing practices and tools.
  • Demonstrated ability to make quick and appropriate judgements on audit findings and translate into needed actions and follow up plans.
  • Must be self-directed, able to function autonomously in all job duties.

 

Company Overview:

Founded in 2018, Longevity Health started as an Institutional Special Needs Plan (ISNP), a type of Medicare Advantage health plan that addresses significant unmet needs of long-term institutionalized members who reside in nursing homes.  Through rapid growth from 2018 to 2022, we expanded our market footprint and currently offer ISNP Medicare Advantage plans in Colorado, Florida, Illinois, Michigan, New Jersey, New York, and North Carolina. 

In 2023, we expanded our service offerings to the broader health plan market.  In addition to our existing markets where we are both the ISNP and the care management team, we are now partnering with National Carriers on their offered ISNP plans in Ohio, Pennsylvania, upstate New York, Georgia, South Carolina, and Texas, with implementations in progress for several other additional US states. This allows us to utilize our core skills of supporting clinical post-acute needs of this vulnerable senior population Currently 13 markets and expanding rapidly.

 

Company Disclaimers:

Longevity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.


It is the policy of Longevity Health to follow Federal and / or State regulations surrounding COVID vaccinations.  While CMS guidelines have been relaxed, there are some LHP facilities which will still require staff be vaccinated in an effort to protect the health of the members / patients we serve.  If your assigned location(s) require all staff to be fully vaccinated, you are required to obtain and / or provide documentation related to your COVID vaccination.  To confirm whether your assigned location(s) require COVID vaccinations, please refer to the Facility Guide Job Aid located on Longevity Health Plan’s intranet site. 

 

The Company will engage in an interactive process with individuals who cannot be vaccinated for medical or sincerely held religious beliefs to determine if a reasonable accommodation can be made. While an exemption/accommodation may be initially granted, if at any time during employment, it is determined that an exemption/accommodation that has been granted is no longer considered a reasonable accommodation, it can result in employment with the Company ending.

 

Candidates must meet the Company’s hiring criteria which include a pre-employment background and drug screening.

 

Longevity Health offers a competitive compensation and benefits package which includes medical, dental, vision, short and long-term disability, life insurance, and 401(k).

 

Submission of false information during the application process may result in immediate termination of employment without notice.