The Capital Blue Cross Government Programs Senior Risk Adjustment Coder plays a key role in ensuring accurate and compliant diagnosis coding to support risk adjustment efforts for Medicare Advantage and ACA lines of business. This position also serves as a mentor to coding staff, leads quality assurance initiatives, and supports provider education and documentation improvement efforts.

• Perform comprehensive review and oversight of medical records for Risk Adjustment compliance keeping with CMS, HHS, and departmental guidelines with a 95%+ accuracy rate.
• Offer suggestions and assistance for improvement in departmental processes & other duties as assigned.
• Actively contribute to departmental process improvement initiatives and support special projects or additional responsibilities as assigned.
• Collaborates with internal teams (e.g., quality, compliance, data analytics) and external stakeholders (e.g., payers, providers, vendors) to support accurate diagnosis capture and improve clinical documentation.
• Maintains responsibility for conducting clinical chart and patient billing audits for the purpose of identifying and validating reported diagnoses for 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.
• Looks for clinical evidence of disease categories, leveraging other sources of information such as lab results, radiology results, and comorbid disease states.
• Performs second-level audits and quality assurance checks on coding done by peers or junior coders.
• Conduct provider training on coding and documentation best practices following Official ICD-10-CM and Capital Internal Coding Guidelines.
• Assists with production coding when needed.
• Onboard new employees.
• Participates in the development and maintenance of Standard Operating Procedures (SOPs), workflows, educational materials, and presentations.
• Serve as a mentor and resource to the team, taking time to assist and being a source of information and insight for projects and daily work.
• Lead communication with the appropriate internal and external stakeholders relevant to auditing results education plans.

Skills:

• Strong analytical skills.
• Ability to problem solve.
• Detail oriented with high degree of accuracy.
• Ability to exercise discretion in handling confidential member information.
• Strong commitment to customer service and understanding and responding to internal and external stakeholder needs within specific timeframes.
• Proficiency with Microsoft Word, Excel and PowerPoint or comparable software required.
• Maintains established work production standards.
• Assumes responsibility for professional growth and development.
• Ability to work independently in a time-oriented environment.
• Review and stay abreast of the latest state and federal regulatory guidelines, Official Coding Guidelines, official coding advice (coding clinic) and all coding updates.
• Proficient with common EMR systems e.g., Allscripts, EPIC, AthenaHealth, PracticeFusion, Medent.
• Ability to manage multiple priorities in a fast-paced, time-sensitive environment.
• Ability to present in individual and group settings.

Knowledge:

• Thorough knowledge of Risk Adjustment Coding
• Knowledge of Medicare and Government programs.
• Current, working knowledge of clinical practice.

Experience:

• 5 years risk adjustment coding experience.
• Familiarity with the CMS Medicare risk algorithm (CMS-HCC) and the ACA risk algorithms (HHSHCC).
• Direct experience speaking with providers required.
• Knowledge of RADV audits.
• Experience teaching/training others on correct coding guidelines required.
• Experience navigating medical records and with clinical documentation.

Education and Certifications:

• Active Certified Risk Adjustment Coder (CRC) credential required.
• Active Certified Professional Coder (CPC), Registered Health Information Technologist (RHIT), or Certified Professional Medical Auditor (CPMA) credential preferred.
• Active nursing credential (RN/LPN) preferred.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.