JOB SUMMARY
The Risk Adjustment Coder II provides advanced support for complex medical record reviews to ensure the correct capture of chronic conditions and complexities to calculate a patient's risk score, by mapping diagnoses to Hierarchical Condition Categories (HCCs) while adhering to CMS guidelines and internal coding policies for the following programs: including, but not limited to, Commercial Risk Adjustment, Medicare Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). The Risk Adjustment Coder II will serve as a subject matter expert for risk adjustment and will assist in the development of team trainings, quality assurance audits, and collaborating with multiple departments across the organization.

JOB SPECIFICATIONS AND CORE COMPETENCIES
Provide advanced complex medical records reviews to identify and code all relevant diagnoses, including chronic conditions, utilizing ICD-10 coding guidelines for Commercial and Medicare risk adjustment programs.
Conduct thorough clinical documentation review to ensure sufficient support and management for coded conditions.
Identify opportunities to improve documentation and coding accuracy; provide analysis and recommendations for improvement to leadership
Consistently meet productivity and quality standards as outlined by supervisor.
Ensure coding compliance by following the Official Coding Guidelines, HHS-RADV Protocols, and attending REGTAP calls.
Stay current with coding standards, risk adjustment methodologies, and CMS Regulatory changes to ensure ongoing compliance and optimal coding practices.
Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.


QUALIFICATIONS: Education/Specialized Training/Licensure:

Bachelor's Degree or 5 or more years of experience in risk adjustment in lieu of degree in managed care organization required.

AHIMA/AAPC Certified Coder, Medical Billing and Coding certification required (CPC, CRC, COC, CCS, CCS-P, or any combination of listed certifications) required.

Associate or bachelor's degree preferred

Work Experience (Years and Area):

3-5 years' experience in Commercial or Medicare risk adjustment coding required.

Clinical documentation improvement experience for inpatient and outpatient preferred.

Experience within a managed care organization preferred.

Management Experience (Years and Area): N/A

Some management experience preferred

Software Proficiencies: Microsoft 365 (Word, Excel, Outlook, SharePoint, Teams)

Other:
Strong analytical skills
Strong written and verbal skills
Strong interpersonal skills Solid knowledge of ACA,
Medicaid, and Medicare Risk Adjustment