Senior Clinical Documentation Integrity, Coding Specialist

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

📋 Description

• Assess medical records to determine the completeness of documentation, clinical specificity, and accuracy of coding.

• Verify ICD-10-CM, CPT, CPT II, and HCPCS coding in relation to supporting clinical documentation and relevant coding guidelines.

• Detect any missing, inconsistent, or unsupported documentation and suggest compliant clarifications or corrections.

• Perform both prospective and retrospective coding reviews.

• Assist with coding audits, initiatives for documentation improvement, and ensuring regulatory compliance.

• Act as an internal coding resource for clinical, quality, and operational teams.

• Facilitate HEDIS medical record review, abstraction, and validation processes.

• Identify documentation that supports compliance with HEDIS measures and appropriate gap closure.

• Examine clinical records for services rendered but not accurately represented in existing clinical or claims data.

• Assess coding opportunities related to CPT II, procedure, and diagnosis codes that are pertinent to quality reporting.

• Aid in supplemental data validation, medical record audits, and data reconciliation activities.

• Review medical records to confirm risk-adjustable diagnoses and the supporting clinical documentation.

• Identify documentation deficiencies, coding errors, and areas for compliant provider clarification.

• Support the accuracy of CMS-HCC coding and the integrity of risk adjustment data.

• Conduct both prospective and retrospective reviews for risk adjustment.

• Assist with audits related to risk adjustment, validation of coding, and initiatives for improving documentation.

• Collaborate with provider-facing teams to enhance documentation of chronic and complex conditions.

• Utilize Inovalon solutions to assist with HEDIS medical record retrieval, abstraction, clinical data validation, risk adjustment, and the identification of coding and documentation opportunities.

• Contribute to the development of standardized workflows, provider education, and internal coding capabilities.

⛳️ Requirements

• Active CPC, CCS, CRC, or another equivalent nationally recognized coding certification.

• At least 3–5 years of pertinent experience in medical coding, clinical documentation improvement, risk adjustment, or clinical data validation.

• Comprehensive knowledge of ICD-10-CM coding guidelines and clinical documentation standards.

• Experience in Medicare Advantage, Managed Care, or Health Plan operations.

• Familiarity with HEDIS quality measurement and CMS-HCC risk adjustment methodologies.

• Background in reviewing medical records for coding accuracy and documentation completeness.

• Strong analytical, communication, and problem-solving abilities.

• Capability to work independently and collaborate effectively across various departments.

• Practical experience with Inovalon solutions that support both HEDIS and risk adjustment workflows.

• Experience with HEDIS medical record retrieval, abstraction, and validation.

• Knowledge of NCQA HEDIS specifications, CMS requirements, and audit processes.

• Experience in supporting D-SNP or I-SNP populations.

• Understanding of CPT II codes and quality-related claims reporting.

• CCDS, CDIP, or other relevant certification.

• Experience in clinical data reconciliation, reporting, and workflow optimization.

• Ability to pass a pre-hire drug screen.

🏝️ Benefits

• Retention bonuses.

• 401k with generous Employer match.

• Medical, Dental, and Vision plans.

• Tuition Reimbursement for BSN after 6 months of employment.

• Exceptional work/life balance - no rotating shifts, holidays, or weekends.

• Partially funded HSA.

• Employee Recognition Platform.

• Paid Time Off, Holidays, and Extended Sick Leave.

• Short/Long term Disability.

• Employee Assistance Program (EAP).