HCC Coding & Risk Adjustment Specialist

Massadvantage; Massachusetts; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated HCC Coding & Risk Adjustment Specialist. This remote role offers the flexibility of 10 hours per week, with potential for more during peak periods. As a key contributor, you will leverage your expertise in coding and critical thinking to ensure accurate documentation and coding compliance. Join a team that values precision and quality in patient care, while enjoying the benefits of a supportive work environment. If you're passionate about making a difference in healthcare and possess the required coding credentials, this opportunity is perfect for you.

Qualifications

• 3+ years of HCC and outpatient coding experience required.
• Certification as a Certified Risk Adjustment Coder (CRC) is mandatory.

Responsibilities

• Interpret clinical documentation for HCC diagnosis selection.
• Perform prospective and retrospective 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

Remote Worker - N/A

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 the 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 10 hours per week, with the possibility of additional hours during weeks with increased volume.

This 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 and use professional discretion in determining and auditing Hierarchical Condition Categories.
• Utilize critical thinking and clinical reasoning to identify, clarify, and query documentation, ensuring accurate representation of patient status.
• Perform comprehensive prospective (pre-visit) and retrospective (post-visit) reviews.
• Ensure full utilization of resources such as medical professionals, CMS risk adjustment algorithms, and AHA/AHMA coding guidelines.
• Analyze medical records and documentation to determine appropriate ICD-10-CM codes as per official guidelines.
• Evaluate clinical records and collaborate with medical professionals to confirm coding determinations.
• Escalate unusual or questionable situations and recommend corrective actions.
• Maintain a coding accuracy rate of at least 95% and meet departmental productivity standards.
• Adhere to coding and billing regulations established by AHA, AMA, and CMS.
• Lead communication with other coding personnel to improve effectiveness and efficiency.
• Attend training and coding in-services annually to stay updated on regulations and guidelines.

Prospective (Pre-Visit) Reviews

• Review medical records prior to visits to identify documentation opportunities and clarifications.
• Accurately enter details into Epic pre-visit workflows.
• Collaborate with medical professionals and partners as needed.
• Track notifications and responses per workflow.
• Review encounter documentation to identify HCCs supported but not submitted, and modify or delete HCCs as appropriate.
• Follow up with medical professionals regarding documentation and HCC adjustments.

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.
• At least two (2) years supporting coding workflows within Epic.
• Thorough knowledge of risk adjustment 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.
• Affiliation with AHIMA or AAPC is preferred.
• Ability to understand HCC financial impacts and recommend workflow improvements.