Healthcare Risk Adjustment Clinical Coding Expert

Job Description:
We are seeking a highly skilled and certified Risk Adjustment Clinical Coding Expert specializing in Medicare Advantage and Affordable Care Act (ACA) lines of business. The ideal candidate will possess a strong clinical background, extensive experience with risk adjustment coding, and a deep understanding of CMS-HCC (Hierarchical Condition Category) risk models.
This role involves analyzing and coding patient data to ensure accurate risk adjustment submissions, working collaboratively with clinical and operational teams, and contributing to compliance with CMS guidelines.

Key Responsibilities:

• Analyze medical records and documentation to identify and validate appropriate HCC risk adjustment codes according to CMS guidelines.
• Ensure coding accuracy and compliance with ICD-10-CM and other relevant standards.
• Provide subject matter expertise in Medicare Advantage and ACA risk adjustment methodologies.
• Collaborate with clinical and operational teams to optimize risk adjustment strategies.
• Review and audit provider coding for accuracy, completeness, and alignment with regulatory requirements.
• Provide training and support to internal teams and external stakeholders on risk adjustment best practices.
• Stay updated on regulatory changes, CMS guidelines, and risk adjustment methodologies impacting Medicare Advantage and ACA programs.

Qualifications:

• Clinical Background: Registered Nurse (RN), Physician Assistant (PA), or similar clinical experience is preferred.
• Certifications: CPC, CRC, or CCS-P certification required. Additional certifications in risk adjustment are a plus.
• Experience:
• Minimum of 3-5 years of experience in risk adjustment coding for Medicare Advantage and/or ACA lines of business.
• Proficient in CMS-HCC risk models and coding guidelines.
• Hands-on experience with risk adjustment tools, EMR systems, and data validation processes.

• Skills:
• Strong analytical and problem-solving skills with attention to detail.
• Excellent communication skills for interfacing with clinical and non-clinical teams.
• Proficiency in understanding and interpreting clinical documentation.

• Knowledge:
• Comprehensive understanding of Medicare Advantage, ACA programs, and related CMS policies.
• Familiarity with RADV (Risk Adjustment Data Validation) audits and submission processes is a plus.

Preferred Qualifications:

• Experience conducting provider education sessions on documentation and coding improvement.
• Familiarity with encounter data submissions and payment integrity processes.
• Advanced knowledge of EMR and risk adjustment software solutions.

Compensation and Benefits:

• Competitive pay, commensurate with experience.
• Flexible working hours with the opportunity to work remotely.
• Opportunity for professional development and certifications in the risk adjustment field.