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About the Role

The Risk Adjustment Coding Specialist is responsible for decision-making and coding reviews to facilitate, obtain, validate, and reconcile provider documentation for clinical conditions that accurately reflect the severity of illness and complexity of patient care.

Responsibilities

• Perform prospective medical record reviews for clinical indicators supportive of an underlying diagnosis.
• Review encounter level patient medical record and provider selected ICD-10-CM diagnosis codes in real time prior to claim submission to validate completeness and accuracy.
• Collaborate with healthcare providers and other stakeholders to clarify documentation and ensure accurate coding and reporting of diagnoses.
• Stay updated on changes to Medicare guidelines, coding regulations, and reimbursement methodologies.
• Participate in coding education and training initiatives for staff.
• Abstract and assign ICD-10-CM diagnosis codes supported in the encounter documentation not initially assigned to the encounter claim.
• Conduct retrospective audits of medical records to validate the accuracy and completeness of diagnosis coding and claim submission.
• Perform comprehensive reviews of provider actions within the Value Based Alert Tool (VBAT) to identify outliers and areas of opportunity.
• Analyze MRA data to identify patterns and assist in the development of interventions at the provider and region level.
• Keep department leadership apprised of project activities through regular written and oral status reports.
• Proactively identify risks that may hinder project success.

Requirements

• High school diploma or GED equivalent.
• Current active coding credential through AAPC or AHIMA required.
• Maintains active professional certification and complies with all educational, professional, and ethical requirements of said certification.
• Minimum of one (1) year of experience in medical field, preferably in an outpatient or accountable care organization setting.
• Proficiency in ICD-10-CM coding guidelines and conventions.
• Knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Familiarity of Medicare risk adjustment methodologies and HCC coding principles.
• Excellent diligence and analytical skills, with the ability to review and interpret complex medical documentation.
• Effective communication and people skills to collaborate with healthcare providers and other team members.
• Ability to work independently and prioritize tasks to meet deadlines in a fast-paced environment.
• Proficiency in electronic health record (EHR) systems.
• Commitment to maintaining confidentiality and adhering to ethical coding standards.
• Minimum of two (2) years coding experience or directly related medical experience, one (1) of which includes Hierarchical Condition Category (HCC) coding.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems.
• Advanced technical skills for use of MS Office (Excel, Word, Access, and PowerPoint).
• Demonstrated ability to utilize a variety of electronic medical records systems.
• Ability to manage significant workload, and to work efficiently under pressure meeting established deadlines with minimal supervision.
• Strong time management skills.
• Must possess high degree of accuracy, efficiency, and dependability.
• Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization both verbally and written.
• Demonstrated organizational and problem-solving ability.
• Strong analytical and mathematical skills.
• Demonstrated experience in project completion, educational program development and/or group presentation.

Skills

• ICD-10-CM coding
• Medical terminology
• Anatomy and physiology
• Major disease processes
• Pharmacology
• Medicare risk adjustment methodologies
• HCC coding principles
• Analytical skills
• Communication skills
• Electronic health record (EHR) systems
• MS Office (Excel, Word, Access, and PowerPoint)

Experience Level

• Minimum of one (1) year of experience in medical field
• Minimum of two (2) years coding experience or directly related medical experience

Education Level

• High school diploma or GED equivalent
• Current active coding credential through AAPC or AHIMA
• CRC designation preferred

Salary/Compensations

• $20.90 to $31.35