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Risk Adjustment Coder

  • R0008596
  • Corporate Office

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Job Description
The Risk Adjustment Coder works in a collaborative effort directly with physicians and their office staff and other support departments to review medical records and other clinical documentation to identify appropriate risk adjustment codes and quality gap closure opportunities.
A major focus of the position is to collect and review documents to support the organization’s quality and risk adjustment initiatives, which results in improving quality of care.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

  • Ensures compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines for Risk Adjustment Reviews of medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify whether:
    • The diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.
    • The diagnosis codes for each chronic or major medical condition have been captured correctly.
  • Any diagnosis code that is unsubstantiated by the record should be queried to provider and assess to accuracy.
  • Reviews for clinical indicators and query providers to capture the severity of illness of the patient.
  • Conducts medical charts to identifying opportunities for improving individual member risk adjustment score accuracy.
  • Provides feedback to internal clients on:
    • Examples of documentation and physician self-coding that do not meet quality standards.
    • Examples of missed operations missed opportunities.
    • Examples of clinical that ensure quality and timely care of our members as well as correct reimbursement.
    • Identifies clinical coding and documentation trends and training needs to improve the quality of documentation to reflect our patients’ health data.
  • Attends all meetings as required.
  • Other duties as assigned and modified at manager’s discretion.

KNOWLEDGE, SKILLS & ABILITIES:

  • Advanced understanding of medical terminology, body systems/anatomy, physiology and concepts of disease processes.
  • Demonstrated ability to utilize a variety of electronic medical records systems.
  • Ability to manage significant work load, and to work efficiently under pressure meeting established deadlines with minimal supervision.
  • Strong time management skills.
  • Excellent written and oral communication for representation of clear and concise results.
  • Strong follow-up skills & organizational skills required.
  • Must possess high degree of accuracy, efficiency and dependability.
  • Candidate will start in office, but could potentially work from home after quality and production levels exceed targets. Would need to be comfortable coming to the office on a weekly basis and as established by management.
  • Travel required 0-10%
Additional Job Description

EDUCATION AND EXPERIENCE CRITERIA:

  • High School Diploma or GED required.
  • Coding Certificate required. APPC or AHIMA coding certified preferred.
  • CRC (certified risk coder) is required, or minimum of 3-5 years’ experience in risk adjusting coding in lieu of certificate.
  • Two (2) + years’ experience in a primary care environment is required.
  • Strong knowledge of Microsoft Office Suite (Excel-basic mathematical formulas, charts, tables).
  • Strong medical coding and third party operating procedures and practices.
  • Knowledge of CPT/ICD-9 & 10 & Medical Terminology.

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