Risk Adjustment Coding Specialist II

Responsibilities  

• 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 the 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 of provider selected ICD-10-CM codes. 

• 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 to ensure compliance and accuracy in coding practices. 

• Participate in coding education and training initiatives for staff to promote consistent and accurate coding practices across the organization. 

• Stays current on applicable coding and documentation guideline changes and rules. 

• This role is expected to maintain a consistent accuracy rate of 95% or higher and able to meet productivity standards established by leadership.  

• Abstract and assign ICD-10-CM diagnosis codes supported in the encounter documentation not initially assigned to the encounter claim following ICD-10-CM Official Guidelines for Coding and Reporting. 

• Conduct retrospective audits of medical records to validate the accuracy and completeness of diagnosis coding and claim submission, identifying and resolving any discrepancies or areas for improvement. 

• 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 when requested assist in the development of interventions at the provider and region level. 

• Keeps department leadership appraised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.