Senior Hierarchical Condition Category (HCC) Coding Specialist

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Senior Hierarchical Condition Category (HCC) Coding Specialist

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Senior Hierarchical Condition Category (HCC) Coding Specialist

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PA, Working at Home - Pennsylvania

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job will deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits. Works closely with colleagues, leadership, enterprise matrix partners (such as quality and compliance), and/or physicians to identify and deliver high quality and accurate risk adjustment coding. Supports all risk adjustment projects to comply with CMS requirements by analyzing physician documentation and interpreting into ICD-10 diagnoses and HCC disease categories. Supports other key objectives to drive capture of accurate risk adjustment coding including documentation improvement, provider education, report analysis, and/or identification of process improvements. Mentors new hires, creates training materials, and delivers training via in-person, virtual, or webinar forums. May also complete analysis on provider coding trends, create and deliver externally facing presentations to improve provider documentation and accuracy, and act as the point-person for the provider office. Required cross-team collaboration for all team projects, including provider outreach, education, and analysis.

ESSENTIAL RESPONSIBILITIES

• Conducts data analyses from medical record reviews; proactively summarizes opportunities to enhance provider documentation to improve coding accuracy and thorough capture of members' chronic health conditions. Conducts quality reviews of high-risk and incremental HCCs and applies expertise to analyze documentation and mitigate risk to the organization. Collaborates with team members to optimize data collection and review, provider education and outreach, and coding quality.20%
• Develops and presents process improvement and training initiatives to improve efficiency and accuracy of departmental coding practices. Regularly presents and contributes to coding education meetings and Annual Coding Summit. Adapts presentation style to audience; provides constructive feedback; presents in-person, virtually and/or by webinar. Completes analytics on providers and/or provider group coding trends and creates and delivers externally facing presentations to provider documentation and accuracy, acts as the point person for the provider office for any questions and additional trainings, as needed.20%
• Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD). Flexes between coding projects, including Retro and Prospective, with different MA, ESRD, and ACA HCC Models; works independently in various coding applications and electronic medical record systems to support departmental goals. Adheres to CMS Guidelines for Coding and Highmark's Policy and Procedures to guide HCC coding decision making. Achieves and maintains coding productivity and quality accuracy metrics set by the management team. 20%
• Contributes to Risk Adjustment Data Validation (RADV) audit coding review, including analysis of claims data to ensure chart acquisition is complete and documentation is comprehensive; applies CMS coding guidelines to validate audited condition(s); assists with review and ranking of charts for submission.10%
• Executes assigned projects in accordance with project plans; monitors progress and makes adjustment as necessary to ensure successful completion. Participate on ad-hoc projects per the direction of leadership to address the needs of the department.10%
• Mentors new hires and coworkers on CMS and Highmark coding guidelines and contributes to onboarding and training material development and enhancement.10%
• May support external vendor quality review(s) to measure coding accuracy, prepare and report findings, and monitor accuracy.10%
• Other duties as assigned.

EDUCATION

Required

• Associate"s degree in medical billing/coding, health insurance, healthcare or related field, or relevant experience and/or education as determined by the company in lieu of degree

Substitutions

• None

Preferred

• None

EXPERIENCE

Required

• 3 year"s in HCC risk adjustment coding experience

Preferred

• 5 year"s in HCC risk adjustment coding experience

LICENSES or CERTIFICATIONS

Required (any of the following)

• Certified Professional Coder (CPC)

• Certified Risk Coder (CRC)

• Certified Coding Specialist (CCS)

• Registered Health Information Technician (RHIT)

Preferred

• None

SKILLS

• Critical Thinking
• Attention to Detail
• Strong Verbal and Written Communication Skills, including Presentation Skills
• Ability to handle manage projects to a successful outcome
• Strong interpersonal skills
• Ability to identify and resolve problems
• Ability to work in a fast-paced, collaborative environment with minimal supervision
• Extensive knowledge of medical terminology and ability to research coding-related questions
• Strong clinical knowledge related to chronic illness diagnosis, treatment, and management
• Microsoft Office Suite Proficient - MS Word, Excel, Outlook, PowerPoint, MS365 and Teams

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Remote Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. x

Pay Range Minimum:

$68,400.00

Pay Range Maximum:

$105,900.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Recruitment Fraud Alert

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Job Details

• Job category Claims
• Position Type Full Time
• Posted 09/03/2026
• Location(s) PA, Working at Home - Pennsylvania
• Line of Business
• Entity
• Recruiter
• Hiring Manager
• Experience Level
• Job Family Quality-HM
• Req ID J286860

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Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

We provide reasonable accommodations to applicants with disabilities or who require accommodations for sincerely held religious beliefs or for known limitations related to pregnancy, childbirth, or related medical conditions. If you need an accommodation, please contact HRServices@highmarkhealth.org. This email is exclusively for accommodation requests under applicable laws.

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