Under the direction of Burden of Illness department leadership, the Risk Adjustment Coding Specialist is responsible for decision-making and coding reviews that help facilitate, obtain, validate, and reconcile provider documentation for clinical conditions that accurately reflect the severity of illness and complexity of patient care.
This role supports prospective medical record review, concurrent outpatient claim diagnosis coding, and retrospective medical record and provider response reviews.
Responsibilities include:
- Perform prospective medical record reviews for clinical indicators supportive of an underlying diagnosis to be presented to a clinician for review during a subsequent face-to-face encounter.
- Review encounter-level patient medical records 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 current on Medicare guidelines, coding regulations, reimbursement methodologies, and documentation rules.
- Participate in coding education and training initiatives to promote consistent and accurate coding practices across the organization.
- Maintain a consistent accuracy rate of 95% or higher and meet productivity standards established by leadership.
- Abstract and assign ICD-10-CM diagnosis codes supported in encounter documentation following official coding guidelines.
- Conduct retrospective audits of medical records to validate the accuracy and completeness of diagnosis coding and claim submission.
- Review provider actions within the Value Based Alert Tool (VBAT) to identify outliers and opportunities for improvement.
- Analyze MRA data to identify patterns and support interventions at the provider and region level when requested.
- Provide regular written and oral status updates to department leadership and proactively identify risks that may affect project success.
- May be assigned additional projects or a higher workload than Risk Adjustment Coding Specialist I.
Requirements & Qualifications
Qualifications
- High school diploma or GED equivalent
- Current active coding credential through AAPC or AHIMA required; CRC preferred
- Active professional certification maintained in compliance with educational, professional, and ethical requirements
- Minimum of 1 year of experience in the 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 with Medicare risk adjustment methodologies and HCC coding principles
- Strong analytical skills and ability to review and interpret complex medical documentation
- Effective communication and people skills for collaboration with providers and team members
- Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment
- Proficiency in electronic health record systems
- Commitment to confidentiality and ethical coding standards
Level II requirements
- Minimum of 2 years of coding experience or directly related medical experience, including 1 year of HCC coding
- Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology
- Extensive knowledge of coding conventions and payment rules related to medical record documentation, billing, and reimbursement systems
- Advanced MS Office skills, including Excel, Word, Access, and PowerPoint
- Experience using a variety of electronic medical record systems
- Ability to manage a significant workload, work efficiently under pressure, and meet deadlines with minimal supervision
- Strong time management skills, accuracy, efficiency, and dependability
- Clear verbal and written communication skills across all organizational levels
- Strong organizational, problem-solving, analytical, and mathematical skills
- Experience in project completion, educational program development, or group presentation
Location
Florida, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago