Overview Job Summary The HCC Coder/Auditor reviews, codes, and audits medical records to ensure accurate risk adjustment reporting and compliance with CMS Risk Adjustment requirements, ICD-10-CM Official Coding Guidelines, and client-specific standards. This position communicates coding findings and documentation improvement opportunities to clients, leadership, and internal teams; maintains audit-ready records; supports education and quality initiatives; and completes retrospective, prospective, and other Medicare Advantage or Risk Adjustment activities as assigned.
Responsibilities
Work Performed and Job Requirements Coding, Auditing, and Quality Review Determine daily assignments through established department and project processes. Access designated client systems to review and code medical records for HCC and Risk Adjustment projects using CMS requirements, ICD-10-CM Official Coding Guidelines, and client-specific standards. Perform coding audits and quality reviews to validate diagnosis-code accuracy and documentation support. Identify undercoded, overcoded, unsupported, and missed diagnoses; document findings and provide clear oral or written coding rationale. Support retrospective and prospective reviews and other Medicare Advantage or Risk Adjustment activities as assigned. Client Engagement & Documentation Improvement Communicate coding findings, trends, and documentation improvement opportunities to clients, management, and internal teams. Prepare and present client and internal education, quality, and coding presentations as requested. Operational & Compliance Support Complete client spreadsheets, databases, audit tools, and other tracking documentation accurately and timely. Maintain established productivity and quality standards and update accurate productivity and quality records. Record time and project activities accurately in designated timekeeping systems. Follow department policies, client instructions, HIPAA requirements, confidentiality standards, and established workflows. Remain current on CMS Risk Adjustment regulations, RADV requirements, ICD-10-CM guidelines, Coding Clinic guidance, and relevant industry practices. Maintain current MARSI and client-system access and report access issues, IT concerns, and system outages through established ticket processes. Work weekends or holidays when required by client demands. Quality Improvement & Education Participate in internal quality assurance, education, and continuous-improvement activities. Assist with development, editing, and periodic quality and content reviews of company school curricula, training materials, articles, and coding resources. Other Duties All other duties as assigned.
Qualifications
Education/Training Minimum of a High School Diploma or equivalent and Certified Risk Adjustment Coder (CRC) certification through AAPC. Certification must remain current and in good standing. CPC, CCS, CCS-P, RHIT, or RHIA certification; Associate’s or bachelor’s degree in health information management or a related healthcare field preferred. Experience Minimum of 5 years of medical coding experience, including at least 3 years of HCC Risk Adjustment coding and/or auditing experience. Experience with Medicare Advantage and CMS Risk Adjustment programs, RADV, retrospective reviews, prospective reviews, and quality assurance activities preferred.
Knowledge, Skills and Abilities
Strong knowledge of ICD-10-CM coding guidelines, conventions, and documentation requirements supporting risk-adjusted diagnoses. Knowledge of CMS Risk Adjustment methodology, HCC coding principles, and medical terminology, anatomy, physiology, disease processes, and pharmacology. Ability to read, analyze, and interpret complex medical records and determine accurate code assignment using official guidelines. Ability to identify coding trends, documentation opportunities, compliance concerns, and process-improvement opportunities. Strong written and verbal communication skills in the English language, including the ability to explain coding rationale clearly. Proficiency with Microsoft Office applications, electronic health records, coding software, databases, spreadsheets, and web-conferencing tools. Excellent organization, attention to detail, prioritization, deductive reasoning, and ability to meet deadlines. Ability to work independently while maintaining productivity, quality, integrity, confidentiality, and professional-development expectations EEO Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c) Additional Info #LI-BR1
