Risk Adjustment Coding Specialist I

verawholehealth; Town of Florida (NY); On-site; USD 65,000 - 95,000; Full time

Job summary

verawholehealth is seeking a Risk Adjustment Coding Specialist to lead prospective and retrospective medical record reviews, validate provider ICD-10-CM codes, and ensure documentation supports diagnoses in alignment with Medicare risk adjustment guidelines.

The role requires strong coding proficiency, EHR system experience, and the ability to work with clinicians to clarify documentation while maintaining high accuracy and productivity in a fast-paced environment.

Qualifications

• Requires a high school diploma or GED.
• Active coding credential through AAPC or AHIMA required; CRC preferred.
• Minimum of 1 year experience in medical field, outpatient or ACO setting preferred.
• Proficiency in ICD-10-CM coding guidelines and conventions.
• Knowledge of medical terminology, anatomy, physiology, pharmacology.
• Familiarity with Medicare risk adjustment methodologies and HCC coding principles.
• Excellent diligence, analytical skills, and ability to interpret complex medical documentation.
• Strong communication and teamwork skills; ability to work independently and meet deadlines.
• Proficiency with electronic health records (EHR) systems.

Responsibilities

• Perform prospective medical record reviews to support diagnoses.
• Review encounter-level records and provider ICD-10-CM codes for completeness and accuracy.
• Collaborate with providers to clarify documentation and ensure accurate coding.
• Stay updated on Medicare guidelines, coding regulations, and reimbursement methods.
• Participate in coding education and training for staff.
• Maintain high accuracy rate (≥95%) and meet productivity standards.
• Abstract and assign ICD-10-CM codes from documentation.
• Conduct retrospective audits to validate coding accuracy and identify improvements.
• Review provider actions in VBAT to identify outliers and opportunities.
• Analyze MRA data to identify patterns and help develop interventions.
• Keep leadership informed with status reports and risk assessments.
• May be assigned additional projects or higher workload.

Skills

ICD-10-CM coding

EHR system proficiency

analytical skills

communication skills

time management

independent work

Medicare risk adjustment knowledge

Education

High school diploma or GED

AAPC/AHIMA coding credential (CRC preferred)

Tools

MS Office

MS Excel

Microsoft Word/PowerPoint/Access

Job description

Job Description Summary

Under the direction of Burden of Illness department leadership, the Risk Adjustment Coding Specialist is responsible for various aspects of decision‑making and coding reviews to facilitate, obtain, validate, and reconcile appropriate provider documentation for clinical conditions that accurately reflect the severity of illness and complexity of patient care.

How will you make an impact & Requirements

This position is responsible for risk adjustment coding and quality assurance validation for the following programs, including but not limited to:

• Prospective medical record review
• Concurrent outpatient claim diagnosis coding
• Retrospective medical record and provider response reviews

Responsibilities

• Perform prospective medical record reviews for clinical indicators supportive of an underlying diagnosis to be presented to a clinician for review during a subsequent face‑to‑face encounter.
• Review the encounter level patient medical record and provider selected ICD-10-CM diagnosis codes in real time prior to claim submission to validate completeness and accuracy of provider selected ICD-10-CM codes.
• Collaborate with healthcare providers and other stakeholders to clarify documentation and ensure accurate coding and reporting of diagnoses.
• Stay updated on changes to Medicare guidelines, coding regulations, and reimbursement methodologies to ensure compliance and accuracy in coding practices.
• Participate in coding education and training initiatives for staff to promote consistent and accurate coding practices across the organization.
• Stays current on applicable coding and documentation guideline changes and rules.
• This role is expected to maintain a consistent accuracy rate of 95% or higher and able to meet productivity standards established by leadership.
• Perform other job‑related duties as assigned by leadership.
• Abstract and assign ICD-10-CM diagnosis codes supported in the encounter documentation not initially assigned to the encounter claim following ICD-10-CM Official Guidelines for Coding and Reporting.
• Conduct retrospective audits of medical records to validate the accuracy and completeness of diagnosis coding and claim submission, identifying and resolving any discrepancies or areas for improvement.
• Perform comprehensive reviews of provider actions within the Value Based Alert Tool (VBAT) to identify outliers and areas of opportunity.
• Analyze MRA data to identify patterns and when requested assist in the development of interventions at the provider and region level.
• Keeps department leadership apprised of project activities through regular written and oral status reports. Proactively identifies risks that may hinder project success.
• May be assigned additional projects/higher work volume than Risk Adjustment Coding Specialist I.

Qualifications

• High school diploma or GED equivalent
• Current active coding credential through AAPC or AHIMA required. Preference given to those with CRC designation.
• Maintains active professional certification and complies with all educational, professional, and ethical requirements of said certification.
• Minimum of one (1) year of experience in medical field, preferably in an outpatient or accountable care organization setting.
• Proficiency in ICD-10-CM coding guidelines and conventions.
• Knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Familiarity of Medicare risk adjustment methodologies and HCC coding principles.
• Excellent diligence and analytical skills, with the ability to review and interpret complex medical documentation.
• Effective communication and people skills to collaborate with healthcare providers and other team members.
• Ability to work independently and prioritize tasks to meet deadlines in a fast‑paced environment.
• Proficiency in electronic health record (EHR) systems.
• Commitment to maintaining confidentiality and adhering to ethical coding standards.

Level II (in addition to minimum qualifications)

• Minimum of two (2) years coding experience or directly related medical experience, one (1) of which includes Hierarchical Condition Category (HCC) coding.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems. This includes a comprehensive understanding of ICD-10-CM.
• Advanced technical skills for use of MS Office (Excel, Word, Access, and PowerPoint).
• Demonstrated ability to utilize a variety of electronic medical records systems.
• Ability to manage significant workload, and to work efficiently under pressure meeting established deadlines with minimal supervision. Strong time management skills. Must possess high degree of accuracy, efficiency, and dependability.
• Demonstrated ability to communicate clearly and effectively with a wide var