Risk Adjustment - Risk Adjustment Coding Analyst 135-2014

JOB SUMMARY:

This role will report directly to the Supervisor of Clinical and Risk Coding and is responsible for clinical and risk adjustment audits for both Medicare Advantage and ACA Programs. Ensuring accurate and appropriate documentation. Audits include Vendors, provider groups, and individual providers. Will also provide medical coding support and HEDIS assistance to the Reporting department. This role will support all seasonal and ad-hoc project assignments for both clinical and risk adjustment.

KEY RESPONSIBILITIES:

• Ensure ICD codes submitted to CMS for the Risk Adjustment Payment System are accurate, appropriate, and supported by written clinical documentation in accordance with all federal and state regulations.
• Adhere to all official coding rules and CMS guidelines for risk adjustment programs. Ensure accuracy, completeness, specificity, and appropriateness of diagnosis information.
• Surveillance of CPT, CMS, and other regulations and their impact related to coding and other business functions.
• Risk Adjustment Validation Audits (RADV), conduct chart review of inpatient and outpatient medical records for Hierarchal Condition Category (HCC) coding.
• Review results of risk adjustment audits to identify coding patterns and provide the information back to the supervisor.
• Provide accurate data results/reports of provider claims and clinical notes audited.
• Recommend general and specific education topics based on CMS/HHS guidelines to the supervisor in written form (e.g., email, word, etc.)
• Meet with the supervisor to discuss potential education with the provider groups and other stakeholders to provide coding education and support.
• Assist with the annual HEDIS medical record review process.
• Receives assignment to evaluate Medicare Wellness Visit documentation for accuracy and completeness in addressing gaps in care and expiring HCCs. Present findings to the supervisor on a regularly scheduled basis.
• Perform evaluation /prioritize results of new Medicare Advantage and Marketplace member self-reported health risk assessments for risk adjustment conditions that should be addressed. Create analyses, summary reporting, and coordinate with providers
• Provide support to health data analysts on medical coding questions and follow up with the supervisor on any issues that need to be resolved.
• Support medical record requests and retrieval projects.
• Perform other job-related duties as assigned.

QUALIFICATIONS:

• Extensive knowledge of ICD, HCPCS, and CPT codes.
• Knowledge of risk adjustment payment models and risk adjustment coding preferred
• Familiarity with State and federal regulations governing healthcare preferred
• Health plan/medical practice experience
• Medicare Advantage and ACA knowledge preferred
• Able to work independently and meet stringent deadlines.
• Strong attention to detail.
• Possess strong oral and written communication skills
• Successful completion of Health Care Sanctions background check.
• Proficient in Microsoft Office applications.

Metric Requirements

Performance will be evaluated using the following indicators:

• Quality

• Audit Accuracy Rate: 95-98% coding accuracy

• Documentation Defensibility Score: 100% alignment with MEAT/ICD-10-CM standards

• Compliance Audit Pass Rate: Minimum threshold set by organization (e.g., 95%)

• Productivity

• Audit Volume: 25-30 charts/cases per day or week (based on specialty and chart type)

• Turnaround Time: Meets established SLA for completion (e.g., 48-72 hours per batch)

• Improvement Impact

• Reduction in Repeat Findings: Continuous improvement trend quarter-to-quarter

• Timely Remediation Rate: 90% of corrections and follow-ups completed within the required timeframe

• Provider/Coder Feedback Engagement: Participation in education aligned with audit trends

• Financial Integrity

• RAF Score Accuracy: Maintains accurate correlation between HCC capture and reimbursement

• Lost Revenue Opportunity Reduction: Identifies and prevents under-coding where compliant and appropriate

EDUCATION/EXPERIENCE:

• Coding certification nationally recognized by the AAPC or AHIMA is required.
• Minimum of two years of coding experience utilizing ICD-CM coding required.
• Experience or familiarity with state and federal regulations governing healthcare.
• Two years' experience with claims processing systems, coding programs, and electronic medical records preferred.
• Previous HMO or health insurance experience preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin