Medical Coder

HireTalent; United States; Vor Ort; USD 90.000 - 120.000; Vollzeit

Zusammenfassung

HireTalent is seeking a Senior Specialist, Risk Adjustment for Medicare Advantage (MA) and ACA. The role focuses on advanced review, interpretation, and validation of clinical documentation and ICD-10-CM coding to support risk adjustment programs.

You will independently assess medical records, adjudicate AI-assisted coding recommendations, and collaborate with clinical and compliance teams to drive accurate risk scoring while meeting regulatory requirements.

Qualifikationen

• Bachelor's degree or commensurate work experience.
• Certified coding credential such as CPC, CRC or AHIMA equivalent required.
• Minimum 3+ years of risk adjustment coding experience for a health plan, provider, or vendor.

Aufgaben

• Independently review medical records to assign accurate ICD-10-CM codes per CMS/ACA.
• Validate and adjudicate AI-assisted coding recommendations with clinical judgment.
• Identify coding trends and opportunities affecting risk adjustment performance.
• Ensure compliance with ICD-10-CM guidelines and risk adjustment standards.
• Collaborate with clinical, operational, and compliance teams on risk initiatives.
• Conduct quality reviews and provide guidance to cross-functional stakeholders.
• Participate in regulatory audits, including Risk Adjustment Data Validation.
• Maintain productivity and manage priorities in a fast-paced environment.

Kenntnisse

ICD-10-CM coding

Risk adjustment concepts

Analytical reasoning

Independent judgment

Ausbildung

Bachelor's degree in a relevant field

Certified professional coder (CPC) / CRC

Tools

EPIC

eClinicalWorks

Athena

Jobbeschreibung

The Senior Specialist, Risk Adjustment for Medicare Advantage (MA) and Affordable Care Act (ACA) is responsible for advanced review, interpretation, and validation of clinical documentation and diagnosis coding related to risk adjustment programs. This role requires independent judgment and decision-making in the evaluation of medical record documentation, identifying coding opportunities, assessing risk, and determining the appropriateness of diagnosis submission. This includes the independent management of deadlines, prioritization, and the timely completion of all coding activities.

Primary Duties and Responsibilities

Independently review and analyze medical records to identify, validate, and assign accurate ICD-10 - CM diagnosis codes in accordance with CMS, ACA, and other applicable risk adjustment methodologies.

• Exercise independent professional judgment when interpreting clinical documentation that is complex or ambiguous using official coding guidelines and payer guidance to determine chronic condition and diagnosis code specificity.
• Review, validate, and adjudicate Ai- assisted coding recommendations using independent clinical judgment to determine accuracy, compliance, and reportability prior to submission
• Identify coding trends, gaps, and opportunities, that impact risk adjustment performance
• Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
• Collaborate with clinical, operational, compliance teams to support risk adjustment initiatives, provider education, and strategic goals.
• Conduct quality reviews, provide guidance, mentorship and education to cross functional shareholders.
• Participate in regulatory audits, including but not limited to Risk Adjustment Data Validation audits
• Maintain productivity and quality standards while timely managing project priorities in a fast paced environment
• Compliance with all applicable laws and regulations

Other duties as assigned

Required Experience and Education

• Bachelor's degree in a relevant field of study or commensurate work experience.
• Certified professional coding credential required such as AAPC CPC, CRC, or equivalent AHIMA CCS, RHIT, or RHIA
• Minimum of 3+ year(s) risk adjustment coding experience for a health plan, provider, or vendor

Preferred Experience and Education

• Certified Risk Adjustment Coder (CRC) or similar certification
• Experience coding in a variety of different Electronic Medical Record (EMR) systems such as EPIC, eClinicalWorks, Athena, etc