The HCC Lead Coder/Auditor is responsible for performing advanced coding and audit reviews of outpatient medical records to validate the integrity of ICD-10 diagnoses and CPT-coded procedures. This role requires deep knowledge of coding guidelines, risk adjustment methodologies, and regulatory requirements to ensure accuracy, compliance, and optimal reimbursement.

Key responsibilities include designing and delivering coding education based on audit findings and regulatory updates, developing training materials, translating complex coding guidelines into actionable guidance, leading clinical documentation improvement efforts aligned with risk adjustment requirements, and supporting client readiness for RADV and/or HRADV audits. The role serves as a subject matter expert in ICD-10 coding and risk adjustment models (CMS-HCC and/or HHS-HCC), providing expert consultation and monitoring regulatory changes.

The position involves performing complex coding and audit reviews using ICD-10-CM, ICD-10-PCS, CPT, validating documentation accuracy, ensuring compliance with regulatory and documentation standards, and communicating findings and recommendations directly to clients.

Additional duties include analyzing audit results to identify trends and opportunities for improvement, supporting quality assurance and continuous improvement initiatives, guiding team members on complex coding scenarios, and maintaining compliance with HIPAA and required training.

Qualifications:

Minimum high school diploma required; associate's or bachelor's degree preferred
Required certifications: AHIMA or AAPC credential (e.g., CPC, CCS-P, RHIA, RHIT, CPMA) and Certified Risk Adjustment Coder (CRC)
Minimum five years of medical coding and/or auditing experience
Strong expertise in CMS-HCC and/or HHS-HCC risk adjustment models
Experience with RADV and/or HRADV audits preferred

Skills include advanced ICD-10 coding knowledge, strong analytical and communication skills, ability to interpret complex medical records, and proficiency with Microsoft Office and coding/audit systems.

This role typically requires independent work and management of multiple priorities in a fast-paced environment.

Minimum high school diploma required; associate's or bachelor's degree preferred
AHIMA or AAPC certification (e.g., CPC, CCS-P, RHIA, RHIT, CPMA) required
Certified Risk Adjustment Coder (CRC) certification required
At least five years of experience in medical coding and/or auditing
Strong knowledge of ICD-10 coding guidelines, medical terminology, and reimbursement methodologies
Proficient in CMS-HCC and/or HHS-HCC risk adjustment models
Experience with RADV and/or HRADV audit processes preferred
Excellent verbal and written communication skills
Ability to work independently and manage multiple priorities
Proficiency with Microsoft Office and coding/audit systems
Compliance with HIPAA regulations