Risk Adjustment Coder

DaMar Staffing; Virginia Beach (VA); On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Tuition Assistance – $5,250/year

Paid Time Off

Bonus opportunities

Job summary

Sentara Health is seeking a Risk Coder to perform compliance activities focused on CMS and HHS risk adjustment. You will review provider coding, support RADV audits, and ensure accurate ICD-10-CM coding to capture appropriate HCCs.

The role requires an associate degree or equivalent coding experience, proficiency in ICD-10-CM, and CRC certification within two years. Experience with CMS/HHS RADV is preferred.

Qualifications

• Associate degree required in healthcare-related field with 2 years of medical coding experience (or 4 years without degree).
• Must know ICD-10-CM Official Coding Guidelines and AHA Coding Clinics.
• One-year prior experience with paper and/or electronic medical records.
• Must obtain CRC certification within two years of employment.
• Prefer CMS/HHS RADV experience and risk adjustment model familiarity.

Responsibilities

• Perform compliance activities focused on CMS/HHS risk adjustment.
• Conduct medical record reviews and RADV audits.
• Review provider coding to ensure CPT/ICD-10-CM alignment with CMS/HHS HCCs.
• Support RADV data validation, medical record retrieval, and vendor coding audits.
• Coordinate risk adjustment gap elimination with clinical and quality teams.
• Serve as SME on risk adjustment diagnosis coding guidelines.

Skills

Risk adjustment knowledge

Coding accuracy

HCC understanding

Education

Associate degree in Healthcare Administration, Nursing, HIM, Accounting or related field

1 year medical coding experience or 4 years if no degree

Certifications: CPC/COC/CIC/CCS-P/CCS/RHIT/RHIA; CRC within 2 years

Tools

ICD-10-CM Coding Guidelines

Job description

Job Title

Risk Coder

Location

Virginia Beach, VA

Work Shift

First (Days)

Job Description

• Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS).
• Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits.
• Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC).
• Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities.
• Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight.
• Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding.
• Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns.
• Serves as subject matter expert on risk adjustment diagnosis coding guidelines.
• Coordinates risk adjustment gap elimination with clinical and quality gap elimination.
• Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.

Education/Certification/Experience

Associate degree required in healthcare administration, nursing, health information management, accounting, finance, or other related field with 2 years of medical coding experience. In lieu of Associates degree, 4 years of medical coding experience required. Must have thorough knowledge and understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics. One-year previous experience with paper and/or electronic medical records required. One of the following certifications are required: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA). Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment. Prefer one-year experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital). Prefer previous experience with CMS, HHS and/or CDPS+RX Hierarchical Condition Categories (HCC) models. Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.

Benefits

Sentara offers an attractive array of full-time benefits to include Medical, Dental, Vision, Paid Time Off, Sick, Tuition Reimbursement, a 401k/403B, 401a, Performance Plus Bonus, Career Advancement Opportunities, Work Perks, and more. Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth. Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Keywords: Talroo-Allied Health, Risk Coder

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission "to improve health every day," this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.