Risk Adjustment Coding Specialist II

Job Description Summary

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Under the direction of Burden of Illness department leadership, the Risk Adjustment Coding Specialist is responsible for various aspects of decision-making and coding reviews to facilitate, obtain, validate, and reconcile appropriate provider documentation for clinical conditions that accurately reflect the severity of illness and complexity of patient care.

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How will you make an impact & Requirements

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This position is responsible for risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

• Prospective medical record review
• Concurrent outpatient claim diagnosis coding
• Retrospective medical record and provider response reviews

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.
• Perform other job-related duties as assigned 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 apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.
• May be assigned additional projects/higher work volume than Risk Adjustment Coding Specialist I

Qualifications

• High school diploma or GED equivalent
• Current active coding credential through AAPC or AHIMA required.
  • Preference given to those with CRC designation.
• 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.

Level II (in addition to minimum qualifications):

• 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. This includes a comprehensive understanding of ICD-10-CM.
• Advanced technical skill