The Risk Adjustment Coder is responsible for reviewing and accurately assigning diagnosis codes to medical records in accordance with ICD-10-CM coding guidelines, CMS-HCC Risk Adjustment methodologies, and client-specific requirements. This role ensures complete and compliant documentation to support accurate risk score capture while maintaining high standards of coding quality, productivity, and regulatory compliance.
Key Responsibilities
- Review outpatient and physician medical records to identify and assign accurate ICD-10-CM diagnosis codes.
- Apply CMS-HCC Risk Adjustment coding guidelines and ensure proper Hierarchical Condition Category (HCC) capture.
- Validate medical documentation to ensure diagnoses are fully supported and compliant with coding standards.
- Maintain coding accuracy while meeting productivity and quality benchmarks.
- Stay current with annual ICD-10-CM, CMS-HCC, and regulatory guideline updates.
- Participate in internal and external coding audits and implement corrective actions when necessary.
- Collaborate with Quality Assurance, Clinical Documentation Improvement (CDI), providers, and Operations teams to resolve coding-related questions.
- Maintain confidentiality and comply with HIPAA, client policies, and company standards.
- Complete assigned coding tasks within required turnaround times.
- Participate in training, calibration sessions, and continuous improvement initiatives.
Qualifications
- Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Occupational Therapy, or any allied health-related course is preferred.
- Active coding certification such as CPC, CRC, CCS, CIC, or equivalent is preferred (CRC is highly preferred for Risk Adjustment coding).
- Minimum of 1–2 years of Risk Adjustment coding experience.
- Strong knowledge of:
- ICD-10-CM coding guidelines
- CMS-HCC Risk Adjustment methodology
- Hierarchical Condition Categories (HCC)
- Medical terminology, anatomy, physiology, and disease processes
- Documentation requirements for accurate diagnosis capture
- Experience working with Electronic Health Records (EHR) and coding software.
- Strong analytical, critical thinking, and problem-solving skills.
- Excellent attention to detail with the ability to consistently meet quality and productivity goals.
- Good written and verbal communication skills.
- Ability to work independently and manage multiple priorities in a fast-paced environment.
Preferred Qualifications
- Certified Risk Adjustment Coder (CRC) credential.
- Experience with Medicare Advantage Risk Adjustment coding.
- Familiarity with RADV audits, provider education, and documentation improvement initiatives.
- Previous experience in a healthcare BPO or outsourcing environment is an advantage.
Key Competencies
- ICD-10-CM Coding
- CMS-HCC Risk Adjustment
- Medical Record Review
- Clinical Documentation Validation
- Quality & Compliance
- Productivity Management
- Attention to Detail
- Critical Thinking
- Time Management
- Collaboration & Communication
