At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
Responsible for supporting providers in improving clinical documentation, risk adjustment coding accuracy, and quality performance related to STARS and HEDIS measures. This role works collaboratively with physicians, medical groups, and internal health plan teams to ensure accurate coding, regulatory compliance, and optimization of value-based care performance.
ESSENTIAL FUNCTIONS
- Educate providers and medical group staff on ICD-10, CPT, and HCC Risk Adjustment coding guidelines. Provide feedback and training to providers to improve documentation specificity and coding accuracy.
- Conduct chart reviews and coding audits to ensure accurate documentation and coding compliance
- Identify coding gaps and missed diagnoses impacting risk adjustment and reimbursement
- Analyze provider performance reports and quality metrics to identify improvement opportunities for STARS and HEDIS measures.
- Support provider participation in value-based programs and performance improvement initiatives
- Collaborate with medical groups to close care gaps and quality measure gaps.
- Develop provider dashboards and reports to support performance improvement.
- Ensure adherence to CMS, Medicare Advantage, Medicaid, and Risk Adjustment guidelines.
- Support internal and external audits related to coding and quality programs.
- Serve as a liaison between medical groups, providers, and health plan quality teams.
EDUCATION
- Bachelor's Degree in Business Administration or Health
EXPERIENCE
- Bachelor’s Degree in Business Administration or Health
Science; with one to three years of related experience. - Certified Coder, CPC or CRC Preferred
LICENSES AND CERTIFICATIONS
COMPETENCIES
- Action Oriented
- Collaborates
- Instills Trust
- Manages Ambiguity
- Customer Delight
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.