The Risk Adjustment Coder is responsible for completing patient assessment forms through electronic and payer portal workflows, supporting retrospective risk sweep processes with payers, and performing accurate and compliant risk adjustment coding. This role reviews medical records and payer-requested documentation, completes and submits required assessment forms within established timelines, resolves workflow exceptions, and collaborates with physicians, practice staff, operational teams, and payer partners to improve RAF accuracy, compliance, and revenue integrity across assigned populations.
Essential duties
- Complete patient assessment forms accurately and timely through designated electronic systems and payer portal workflows using available medical-record documentation.
- Manage assigned payer portal queues, including case intake, form completion, submission, status tracking, follow-up, and resolution of rejected, incomplete, or returned items.
- Support retrospective risk sweep processes with payers by reviewing requested populations and medical records, identifying supported diagnoses, completing required documentation, and meeting payer-specific deadlines.
- Conduct retrospective documentation reviews to validate diagnosis capture, coding accuracy, and compliance with CMS, ICD-10-CM, payer, and organizational guidelines.
- Perform two-sided chart reviews to identify documentation gaps, unsupported diagnoses, and opportunities for recapture and greater coding specificity.
- Evaluate medical records for complete and compliant support of submitted diagnoses, including assessment of M.E.A.T. criteria where applicable.
- Apply current risk adjustment coding and payer-specific guidance, and escalate complex cases, portal issues, or documentation deficiencies as appropriate.
- Maintain complete audit trails and accurate documentation of review outcomes, form submissions, payer responses, and outstanding follow-up items.
- Support physician and practice education related to patient assessment documentation, HCC capture, coding guidelines, and review findings.
- Assist with new PCP onboarding by providing approved training resources and guidance on risk adjustment documentation, assessment forms, and coding expectations.
- Collaborate with coding, clinical, operational, and payer-facing stakeholders to meet program timelines and improve coding accuracy, documentation quality, and risk adjustment performance.
Measurable goals
- Meet assigned patient assessment form volume, accuracy, and turnaround-time targets.
- Complete payer portal submissions and required follow-up within payer and organizational deadlines.
- Maintain established standards for coding accuracy, documentation quality, submission completeness, and audit compliance.
- Complete assigned retrospective payer risk sweep work accurately and within defined campaign timelines.
- Maintain accurate status tracking and timely resolution or escalation of incomplete, rejected, or returned submissions.
Requirements & Qualifications
Qualifications
- Minimum 2 years of professional coding experience required.
- Experience with risk adjustment, coding audit, medical-record review, patient assessment form completion, payer portal workflows, or retrospective payer risk sweep work preferred.
- Working knowledge of HCC methodologies, including CMS-HCC, HHS-HCC, and CDP logic.
- Knowledge of ICD-10-CM coding guidelines, CMS and payer risk adjustment requirements, and compliant documentation standards.
- Ability to accurately complete patient assessment forms from medical-record documentation and follow payer-specific submission requirements.
- Ability to navigate multiple electronic systems and payer portals, manage work queues, track submission status, and resolve or escalate workflow exceptions.
- Ability to review medical records, identify documentation gaps, and apply coding guidance accurately and consistently during retrospective review activities.
- Clear written and verbal communication skills for coordinating with physicians, practice staff, operational teams, and payer-facing stakeholders.
- Strong organizational skills and the ability to manage concurrent payer workflows, assigned reviews, deadlines, and detailed audit trails in a fast-paced environment.
- CRC, CPC, CCS, or an equivalent nationally recognized coding certification required within 18 months of hire.
- Associate degree or completion of an accredited coding program preferred.
- Experience in Medicare Advantage, ACA commercial risk adjustment, value-based care, managed care, and/or provider education preferred.
Location
Florida, US
Employment Type
Not specified
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
1 month ago