Risk Adjustment Coding Specialist II
Job Description Summary
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.
How will you make an impact & Requirements
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 con