HCC Coding Auditor - Health Plan Network

CHILDREN'S HOSPITAL OF SAN ANTONIO; Irving (TX); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Children's Hospital of San Antonio seeks an HCC Coding Auditor to perform audits and abstractions using ICD-10-CM guidelines and AHA Coding Clinic guidance. The role supports Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, and RADV programs in a hybrid-work setting.

The position emphasizes quality assurance, education on documentation practices, and regulatory compliance, ensuring accurate coding and recapture of chronic conditions while improving documentation.

Qualifications

• High School diploma or equivalent is required.
• Excellent verbal and written communication skills.
• Minimum 1 year of hospital inpatient/outpatient or risk adjustment coding experience OR 3+ years in related areas.

Responsibilities

• Meets the applicable OneCHRISTUS competencies and leads self or others.
• Performs medical record reviews and audits for risk adjustment coding adherence.
• Audits code abstraction to ensure ICD-10-CM codes are accurately assigned and supported by documentation.
• Performs coding quality audits across EMRs, databases, or vendor platforms.
• Identifies revenue, reimbursement, and provider education opportunities while complying with regulations.
• Provides auditing analyses and feedback on noncompliance issues.

Skills

Verbal communication

Written communication

Education

High School diploma or equivalent

Job description

Hcc Coding Auditor

The HCC Coding Auditor will perform code audits and abstractions using the Official Coding Guidelines for ICD-10-CM and AHA Coding Clinic Guidance, following all state regulations, federal regulations, internal policies, and internal procedures. The HCC Coding Auditor will be involved with quality assurance auditing and risk adjustment code abstraction for the following programs: Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). This is a hybrid role.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Performs Medical Record reviews and audits based on organizational priorities. These can include prospective and concurrent Clinical Documentation Improvement (CDI) workflows and retrospective auditing. Review and audits may lead to the addition, deletion, adjustment, or confirmation of diagnoses for risk adjustment.
• Performs code abstraction and/or coding quality audits of medical records to ensure ICD-10CM codes are accurately assigned and supported by clinical documentation to ensure adherence with CMS (HCC) Risk Adjustment guidelines.
• Performs coding quality audits within multiple EMRs, databases, and/or vendor platforms to support employed and independent clinic risk adjustment strategies.
• Identifies revenue, reimbursement, and provider educational opportunities while complying with state and federal regulations.
• Prepares and/or performs auditing analysis and provides feedback on noncompliance issues detected through auditing.
• Complies with all aspects of coding, abides by all ethical standards, and adheres to official coding guidelines.
• Provides measurable, actionable solutions to providers that will result in improved accuracy for documentation and coding practices to ensure chronic conditions are recaptured annually.
• Ensures that rendered physician services for claim submission and any subsequent payments are as accurate as possible while complying with regulatory guidelines, including CMS, DHS, and OIG.
• Assist coding leadership by making recommendations for process improvements to enhance coding quality goals and outcomes further.
• Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations by utilizing the current ICD-10-CM manual and other relevant materials.

Job Requirements:

Education/Skills

• High School diploma or equivalent is required.
• Excellent verbal and written communication skills.

Experience

• Minimum of 1 year of experience in hospital inpatient/outpatient settings, medical office coding, or risk adjustment coding OR 3+ years of experience in one or more of the following areas: Claims Processing, Insurance Verification, Provider Credentialing, Member Services, Member Enrollment, Medical Records Management, Health Information Management, Medical Assisting, Nursing, Billing, Benefits and Eligibility, or Provider Education.

Licenses, Registrations, or Certifications

• Coding certification from AAPC or AHIMA is required within six (6) months of hire:
  • Certified Professional Coder (CPC)
  • Certified Professional Coder-Apprentice (CPC-A)
  • Certified Risk Adjustment Coder (CRC)
  • Certified Risk Adjustment Coder-Apprentice (CRC-A)
  • Certified Coding Associate (CCA)
  • Certified Coding Specialist (CCS)
  • Registered Health Information Management Technician (RHIT)
  • Certified Coding Specialist for Providers (CPMA)
  • Certified Coding Specialist for Providers (CDEO)

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time