Job Title: Risk Adjustment Coding Specialist (CRC)
Location: Reston, VA (100 Remote Job, Work from home)
Duration: 12 Months+
Purpose:
The Risk Adjustment Coding Specialist supports the retrospective risk adjustment supplemental filing, HHS-Risk Adjustment Data Validation (RADV) audit and any other chart coding functions, by performing moderately complex medical record review and coding, ensuring compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines. The development and ongoing maintenance of the Commercial Risk Adjustment Coding guidelines, as well as, guiding junior coding specialists are included in the job responsibilities.
Essential Functions:
45% Verifies accuracy, completeness, and appropriateness of diagnosis codes based on medical documentation provided at all levels of complexity. Utilizes appropriate coding guidelines and recommends any changes to diagnosis codes based on chart review. Achieves and maintains coding accuracy levels greater than 90%. Works with vendors, providers and hospital staff to coordinate record access.
30% Identifies and documents coding observations or discrepancies and provides information to management team to further enhance quality and/or provider education. Work with leadership and third-party vendors to negotiate agreement on complex medical record diagnoses and determine compliance with coding guidelines which will be accepted by the federal government. Develops and conducts new physician/other healthcare practitioner coding orientation/education, including group or individual sessions. Develop and maintain coding guidelines for Commercial Risk Adjustment, maintaining those guidelines for any changes in industry standards.
25% Provide guidance and direction to Coding Specialists when reviewing complex medical records to help guide in determining appropriate coding.
Individual Contributor - Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
SCOPE
Freedom to Act
Work is accomplished with limited direction. Determines and develops approach to solutions. Work is evaluated upon completion to ensure objectives have been met.
Problem Complexity and Problem Solving Timeframes
Provides resolution to an assortment of problems that are typically well defined, but some clarification or judgment is required to determine action, as additional information about the problem / task is discovered. Uses judgment within defined practices / procedures to determine appropriate action. Problem/Task resolution timeframe: Inclusive of shorter timeframes, but the majority of tasks take up to several weeks to resolve.
Education Details: Health Information Technology, Business or related field
Required Experience:
3-5 years risk adjustment/hierarchical condition category (HCC) coding experience
Strong expertise in ICD-10-CM coding, especially for Commercial Risk Adjustment
Ability to interpret moderately complex to complex medical records
Deep understanding of CMS, HHS, RADV, and risk adjustment coding and documentation guidelines
CRC required
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