Medical Risk Adjustment Coder

• Collaborates with a variety of internal and external clients, including health care executives, physicians, provider office personnel, and payer representatives from various health plans to streamline and optimize accurate diagnosis code capture.
• Maintains responsibility for conducting clinical chart and patient billing audits for the purpose of
• Identifying and validating reported diagnoses for Medicare/Medicare Advantage and ACO health plan members.
• Reviews medical records and billing history to determine if specific disease conditions were correctly billed and documented.
• Adheres to all official coding rules and CMS guidelines for risk adjustment, and ensures accuracy,
• Completeness, specificity and appropriateness of diagnosis information.
• Assists with the completion of HEDIS chart reviews and facilitates the accurate and timely reporting of quality measures. .
• Demonstrates analytical and problem-solving ability in the process of reviewing submitted
• Diagnosis codes, comparing to actual services provided to the patient, and communicates appropriate feedback to providers and billing personnel.
• Performs analysis and focused chart reviews for targeted provider education training projects.
• Assists in the acquisition, development and distribution of coding and documentation improvement educational materials.
• Provides articles for the quarterly coding newsletter.
• Facilitates collection, validation, distribution and follow-through support of monthly and quarterly HCC coding reports for all providers participating in the Managed Medicare Program and Accountable Care Organization Programs.
• Places emphasis on compliance with Risk Adjustment procedures and protocol, internal controls, and maintaining the highest level of workplace behavior.
• Coordinates data collection and aggregation on a variety of focused audits and HCC coding capture projects.
• Validates the results of payer audits and translates findings into educational opportunities and tools to optimize revenue recovery.
• Offers support in the Care Coordination Department, focusing on provider and staff education.
• Facilitates ongoing quality metrics monitoring & assists with providing quarterly quality metrics reports for each PCP.
• Performs data validation and integrity functions in a variety of systems pertaining to patient care, clinical documentation, charge entry & billing, and payer claims management.
• Documents and reports activities regarding program status.
• Reviews, analyzes and modifies data as necessary to meet both internal and external customer needs
• Works with clinical staff to analyze reports and collaboratively identify improvement opportunities.
• Monitors quality, cost and efficiency on a recurring basis.
• Remains available when needed to attend Managed Medicare meetings, record minutes, and translate meeting outcomes into action plans that yield measurable results.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
• Maintains compliance with all Orlando Health policies and procedures.

• Maintains established work production standards.
• Assumes the responsibility for professional growth and development.
• Ability to work independently in a time-oriented environment.
• Participates in professional healthcare and community associations to keep abreast of current healthcare trends is expected

• Maintains established work production standards.
• Assumes the responsibility for professional growth and development.
• Ability to work independently in a time-oriented environment.
• Participates in professional healthcare and community associations to keep abreast of current healthcare trends is expected

• High school graduate or equivalent.

Must maintain current one of the following:

• Certified Professional Coder (CPC)
• Certified Risk Adjustment Coder (CRC)

• Prior HCC/HHS experience with Medicare Risk Adjustment with two (2) years’ experience in medical coding.
• Computer literate with skills in Windows, Microsoft Word, Microsoft PowerPoint, Microsoft Excel.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.