The Risk Adjustment Specialist- Medical Coder Assists in the development and implementation of systems and processes to ensure the integrity of diagnostic coding and reporting, directly impacting the financial performance and compliance of the PACE programs. Acts as a liaison between PACE providers and contracted providers to ensure timely response to inquiries and opportunities/findings resulting from audits.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education: Associate’s degree in Health Information Management or related field.
• Certification: Current certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
• Experience: Minimum of five (5) years of experience working directly with diagnostic and procedural coding required. Strong preference for substantial experience with Hierarchical Condition Categories (HCCs) and risk adjustment methodologies.

ESSENTIAL FUNCTIONS:

Collaboration for Risk Adjustment Integrity:

• Works closely with Medical Directors and PACE providers to uphold the integrity and accuracy of the risk adjustment reporting process.

• Engages in continuous dialogue with healthcare professionals to ensure that coding accurately reflects participant acuity.

Medication Documentation Review and Diagnostic Coding:

• Reviews and interprets provider documentation to extract critical information.

• Assigns ICD-10-CM/CPT/HCPCS codes to diagnoses and procedures from documented information in the medical record.

• Assures the final diagnoses and procedures are valid and complete.

• Communicates and resolves coding issues (lacking documentation, provider queries, etc.).

Liaison Role:

• Acts as a key intermediary between PACE providers and contracted coding services.

• Ensures timely and effective response to coding-related inquiries and issues.

Coding Compliance and Data Analysis:

• Facilitates the audit review process, collaborating with providers to resolve individual and systemic coding issues.

• Leads efforts to enhance coding accuracy and compliance through regular, targeted audits.

• Performs data analysis to uncover and seize missed coding opportunities.

Report Review and Response Process:

• Works with clinical leadership to devise and implement procedures for generating and distributing participant specific-reports.

• Ensures these reports are reviewed by the provider during subsequent participant clinic visits, maintaining a system for tracking and ensuring accountability.

Encounter Reporting Support:

• Applies coding expertise to support the accuracy of the encounter reporting process in applicable programs. Acts as a resource for program leadership in determining the appropriateness of coding used for encounters.

Systems and Process Improvement:

• Assists in the continuous improvement of systems and processes to better align with the organization’s strategic goals.

• Contributes to the development of initiatives that enhance the efficiency and accuracy of coding practices.

Remote Work and Accountability:

Work independently in remote setting, demonstrating high level of responsibility and accountability.

Collaborate with cross-functional teams as needed