Coder (Risk Adjustment)

The Coder manages the day to day responsibilities of chart abstraction and reporting in accordance with state and federal regulations. The coder will abstract from inpatient and outpatient medical records and record findings via electronic data base and/or excel spread sheets. The coder ensures that all claims accurately reflect the appropriate diagnosis information as outlined in the member’s medial record. The coder will respond to interdepartmental and provider inquiries guaranteeing that all work is in compliance with internal protocols and external compliance requirements.

Key Functions/Responsibilities:

• Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation.
• Document coding review may lead to the addition, deletion, adjustment, or confirmation of diagnoses.
• Maintain current knowledge of ICD-10-CM codes, CMS documentation requirements, and state and federal regulations.
• Ensure accurate coding for Medicaid members using the DxCG and CDPS risk models.
• Ensure accurate coding for Medicare members across all models including RADV audits.
• Assist coding leadership by making recommendations for process improvements to further enhance coding quality goals and outcomes.
• Handle other related duties as required or assigned, including Provider Training and working with vendor partners.
• Coders assist with code abstraction and coding quality audits using the Official Coding Guidelines for ICD-10-CM, AHA Coding Clinic Guidance, and in accordance with all state regulations, federal regulations, internal policies, and internal procedures.

Qualifications:

Education:

• Completion of an accredited medical coding program with current certification.
• CPC is mandatory
• CRC in addition is helpful

Experience Required:

• Minimum of 5 years coding experience with 3 years Risk Adjustment coding/auditing

Experience Preferred/Desirable:

• Risk Adjustment, Provider Training and RADV work.
• Massachusetts’s Medicaid DxCG risk model experience.
• HCC coding experience
• CDPS risk model experience.

Competencies, Skills, and Attributes:

• Strong analytical and problem solving skills.
• Strong oral and written communication skills
• Strong organization and time management skills
• Ability to work independently in a remote home based environment
• Experience with standard Microsoft Office applications, particularly MS Excel and MS Word
• Ability to multi-task