Company Description Lumen Solutions Group Inc. is a technology consulting Services company based in Florida. We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, Enterprise Transformation. Job Title: Risk Adjustment Coding Specialist Location: Remote (primarily remote; onsite once a quarter or as needed) Type: Contract to Hire Job Summary: We are seeking experienced and certified Medical Coders to join our Special Investigation Unit (SIU) at CareFirst. This team plays a critical role in fraud detection and prevention, focusing on prepayment claim reviews. Responsibilities: Review medical records and claims for coding accuracy and compliance. Identify potential fraud, waste, or abuse through prepayment reviews. Apply correct CPT, ICD, and HCPCS codes per medical and payment policies. Make recommendations for claim approval or denial. Collaborate with investigators and SIU team members. Utilize coding tools such as Optum or Coder Pro. Qualifications: 2–3 years of medical coding experience. Certification required: CPC, CPMA, CCA, or COC (CPCA not accepted). Strong knowledge of fraud detection, claims policies, and medical policy guidelines. Familiarity with prepayment review workflows preferred. Perform risk adjustment coding primarily for Medicare Advantage plans Review and abstract medical records accurately Conduct RADV (Risk Adjustment Data Validation) coding and auditing Work in a high-volume, production-driven environment Use Microsoft Excel for basic tracking and reporting of coding data Ensure compliance with MEAT criteria (Monitor, Evaluate, Assess, Treat) for diagnosis validation Qualifications: CRC Certification (Certified Risk Adjustment Coder) – Mandatory Minimum 3+ years of Risk Adjustment Coding experience Hands-on experience with: RADV coding Auditing Strong knowledge of: ICD coding guidelines Risk adjustment methodologies Ability to work efficiently in a production-based environment Basic proficiency in Microsoft Excel Preferred Qualifications: CPC Certification (Certified Professional Coder) – Nice to have Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.L
Lumen Solutions Group Inc