Contract HCC Coding & Risk Adjustment Specialist

Freddie Mac; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Contract HCC Coding & Risk Adjustment Specialist to enhance their Medicare Advantage health plan. This role involves interpreting clinical documentation and ensuring accurate coding to optimize patient care and reimbursement. You will work closely with medical professionals, utilizing your expertise in HCC coding and ICD-10-CM guidelines. With a commitment to quality and compliance, you will play a crucial role in supporting efficient workflows and maintaining high standards in coding accuracy. If you have a passion for healthcare and coding, this opportunity is perfect for you.

Qualifications

• Bachelor's degree or equivalent experience required.
• Certification as Certified Risk Adjustment Coder (CRC) is mandatory.
• 3+ years of HCC coding experience needed.

Responsibilities

• Interpret clinical documentation for HCC diagnosis selection.
• Perform pre-visit and post-visit reviews of medical records.
• Maintain a coding accuracy rate of at least 95%.

Skills

HCC Coding

ICD-10-CM Coding

Critical Thinking

Clinical Reasoning

Documentation Review

Education

Bachelor's Degree

Certified Risk Adjustment Coder (CRC)

Medical Coding Training

Tools

Epic

Job description

Job Type

Contract

Description

Mass Advantage is a Medicare Advantage health plan located in Worcester, MA. We are affiliated with UMass Memorial Health, the largest healthcare system in Central Massachusetts and a clinical partner of the University of Massachusetts Chan Medical School, providing access to the latest technology, research, and clinical trials.

We are seeking a Contract (1099) HCC Coding & Risk Adjustment Specialist. This position requires approximately 10 hours per week, with potential for additional hours during periods of increased volume.

The individual will interpret clinical and diagnostic documentation to identify opportunities for Hierarchical Condition Category (HCC) diagnosis selection, suspicion, and/or removal, following official coding guidelines for prospective and retrospective reviews.

Essential Duties and Responsibilities:

• Serve as a subject matter expert, using professional discretion to determine and audit Hierarchical Condition Categories.
• Utilize critical thinking and clinical reasoning to identify, clarify, and query documentation, ensuring accurate representation of patient clinical status.
• Perform comprehensive prospective (pre-visit) and retrospective (post-visit) reviews.
• Utilize available resources such as medical professionals, CMS risk adjustment algorithms, and AHA/AHMA coding guidelines.
• Analyze medical records and encounter documentation to assign appropriate ICD-10-CM codes as per official coding guidelines and recognized references.
• Evaluate clinical records and collaborate with medical professionals to confirm coding determinations.
• Escalate unusual or questionable situations, irregularities, or policy violations, and recommend corrective actions.
• Maintain a coding accuracy rate of at least 95% to ensure optimal reimbursement and meet departmental productivity standards.
• Adhere to coding and billing regulations established by AHA, AMA, and CMS.
• Lead communication efforts with coding personnel to improve overall efficiency.
• Participate in annual training and coding in-services to stay current with regulations and guidelines.

Prospective (Pre-Visit) Reviews

• Review medical records prior to visits, including physician notes, labs, hospital records, imaging, and prescriptions, to identify documentation opportunities and clarifications.
• Accurately document details in Epic pre-visit workflow notifications to prepare physicians and practices.
• Collaborate with medical professionals and business partners as needed.
• Track notifications and responses per workflow.

Retrospective (Post-Visit) Reviews

• Review encounter documentation to identify HCCs supported by documentation but not submitted, and modify or delete HCCs as appropriate.
• Follow up with medical professionals to query and clarify documentation for HCC adjustments.
• Track relevant information per workflow.

Requirements

• Bachelor's degree or equivalent experience.
• Certification as Certified Risk Adjustment Coder (CRC) is required.
• At least three (3) years of HCC and/or outpatient coding experience.
• Minimum of two (2) years supporting coding workflows within Epic.
• Thorough knowledge of risk adjustment payment methodologies.
• Thorough knowledge of ICD-10-CM coding (current edition).
• Understanding of third-party payer requirements and federal/state regulations related to coding and billing.
• Completion of accredited medical coding training and medical terminology courses.
• Membership or certification from AHIMA or AAPC is preferred.
• Ability to understand HCC financial impacts and develop workflow enhancements.