Medicare Risk Adjustment Coding Specialist

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Assess medical records, patient medical history, physical examinations, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, as well as discharge summaries to ensure the accuracy, completeness, specificity, and appropriateness of diagnosis codes.

• Assist in validation audits to review medical record documentation, confirming that coding accurately represents and supports the relevant coding aligned with the ICD-10 code submitted to CMS for reimbursement.

• Analyze medical documentation to ensure all pertinent coding based on CMS Hierarchical Condition Categories (HCC) related to Medicare Risk Adjustment reimbursement initiatives is adequately captured.

• Create tools and metrics aimed at enhancing the accuracy and completeness of coding and documentation.

• Deliver exceptional customer service to both internal and external clients by meeting and exceeding expectations regarding quality and productivity standards.

• Escalate relevant coding audit issues to management as necessary.

• Engage in and support ad-hoc coding audits as required.

• Assist in ongoing programs designed to mitigate organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit.

• Complete assigned coding projects efficiently.

• Perform additional duties as assigned.

⛳️ Requirements

• Maintain a thorough understanding of current CMS regulations and announcements impacting risk adjustment.

• Adhere to all relevant Federal and state regulatory requirements and guidelines, along with company policies and procedures.

• Meet established production and quality standards consistently.

• Possess knowledge of CMS requirements related to claims processing and coding.

• Be knowledgeable about coding and auditing claims for Medicare and Medicaid plans.

• Have extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing.

• Exhibit strong interpersonal skills.

• Demonstrate excellent written and verbal communication abilities.

• Possess strong organizational skills and the capability to manage time effectively.

• Uphold confidentiality.

• Exhibit strong analytical and critical thinking skills.

• Ability to work remotely without direct oversight.

• Successfully complete all required training.

• Effectively manage multiple priorities.

• Education: High school diploma or equivalent.

• Experience: A minimum of 2 years of experience in complex claims processing and/or coding auditing within the health insurance sector or medical health care delivery system.

• 2 years of experience in a managed healthcare environment related to claims and/or coding audits.

• 2 years of experience with standard coding and reference materials used in claims settings such as CPT4, ICD10, HCPCS, and others.

• 2 years of experience with CMS requirements regarding claims processing and coding.

• 2 years of experience coding and auditing claims for Medicare and Medicaid plans.

• Significant experience with HCC, including knowledge of HCC mapping and hierarchy.

• License/Certification: A coding certification is required (CPC or CRC).

🏝️ Benefits

• Affordable Medical/Dental/Vision insurance options.

• Generous paid time-off program and paid holidays for full-time staff.

• TeleDoc 24/7/365 access to doctors.

• Optional short- and long-term disability plans.

• Employee Assistance Plan (EAP).

• 401K retirement plans with company matching.

• Employee Referral Bonus Program.