Senior Risk Adjustment Coding Specialist

2 weeks ago

Canton, Massachusetts, United States Point32Health Full time

Position Overview
Under the supervision of the Risk Adjustment Supervisor/Manager, the Senior Risk Adjustment Coding Specialist is responsible for the precise and prompt assessment and confirmation of Medicare Advantage, Commercial, and Medicaid Hierarchical Condition Categories (HCCs) through comprehensive medical record evaluations.

Key Responsibilities
The Senior Specialist will meticulously review provider documentation of ICD-10-CM (and ICD-9-CM) codes to ensure compliance with established coding standards, as well as adherence to CMS and ACA Risk Adjustment protocols.

This role involves leading initiatives to assess HCC coding practices and offering insights and recommendations aimed at enhancing overall provider documentation and coding accuracy.

The Senior Risk Adjustment Coding Specialist will conduct thorough medical record reviews to ascertain that diagnostic codes (ICD-9/10-CM) accurately represent the provider documentation.

Additionally, this position requires summarizing findings for both internal and external stakeholders. The Specialist will engage in a variety of audit projects, particularly those with significant business implications, necessitating advanced expertise and experience in risk adjustment coding.

Quality Control and Training
Occasionally, the Senior Specialist will perform quality control (QC) checks on the work conducted by Coding Specialists I and II, providing guidance on accurate coding standards. They may also facilitate coding and documentation training sessions for network providers and their coding teams.

Audit and Compliance
Responsibilities include conducting ongoing audits of medical records from coding vendors and network providers to ensure diagnostic coding accuracy. The Specialist will evaluate medical records for appropriate signatures and other technical requirements.

Collaboration with internal staff and vendors is essential to identify and submit necessary coding adjustments. The role also encompasses performing HHS-RADV Audits, which includes preparing charts for Initial Validation Auditors (IVA) and evaluating IVA results. When applicable, the Specialist will provide relevant ICD-10-CM Guidelines, AHA Coding Clinic references, and/or CMS Guidelines to substantiate the validity of ICD-10-CM code assignments.

Continuous Learning
Maintaining a current and robust understanding of coding regulations and CMS guidelines in both inpatient and outpatient environments is critical. The Senior Specialist must prioritize compliant interpretation and integration of ICD-10-CM and ICD-9-CM coding guidelines and CMS regulations into their audit work promptly.

Furthermore, they will research and resolve coding inquiries and risk adjustment regulatory challenges.

Qualifications
A formal coding certification program completion is required, along with certification as a Certified Professional Coder (CPC-A, CPC, CPC-H, COC, CIC, or CRC) or Certified Coding Specialist (CCS-P or CCS). Proficiency in ICD-10-CM coding and CRC certification is mandatory. A minimum of 7 years of coding experience is preferred, particularly in a health plan, hospital, or physician practice environment.

Prior experience in Risk Adjustment coding and auditing is advantageous, especially for candidates with 5 or more years in a provider-facing role.

Commitment to Diversity, Equity & Inclusion
Point32Health is dedicated to integrating diversity, equity, and inclusion into all aspects of our operations—from product design to workforce development.

Our DEI strategy aligns with our core values and adapts to the evolving nature of work.

We welcome all applicants and qualified individuals, ensuring consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

About Point32Health
Point32Health is a prominent health and wellbeing organization committed to delivering an enhanced personalized healthcare experience to all members of our communities.

Building on the quality, nonprofit legacy of our founding organizations, we leverage our expertise to assist individuals in achieving their health goals through a comprehensive range of health plans and resources.

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