The Capital Blue Cross Government Programs 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. The coder is responsible for reviewing both inpatient and outpatient medical records to identify and validate ICD-10-CM diagnoses that impact risk scores. This position also supports CMS and HHS Risk Adjustment Data Validation (RADV) activities to ensure regulatory compliance and data integrity.

• Perform comprehensive reviews of medical records (including retrospective, prospective, and in-home assessments) to ensure compliance with CMS and departmental risk adjustment guidelines.
• Conduct chart audits to identify undocumented or underreported chronic conditions.
• Actively contribute to departmental process improvement initiatives and support special projects or additional responsibilities as assigned.
• Collaborate with internal teams and external stakeholders, including providers, payers, and healthcare executives, to support accurate diagnosis capture and improve clinical documentation.
• Maintain productivity and accuracy benchmarks, ensuring all diagnosis coding is accurate, complete, specific, and appropriate.
• Review documentation within multiple EMRs, databases, and/or vendor platforms to appropriately assign ICD-10-CM diagnoses.
• Stay current on risk adjustment policies, HCC updates, and official coding guidelines; obtain necessary continuing education units (CEUs) and complete required training.
• Independently apply critical thinking to capture Hierarchical Condition Categories (HCCs) correctly and flag any coding trends for leadership review.
• Identifies coding trends to be escalated to leadership.
• Follows official coding standards and CMS (Centers for Medicare and Medicaid Services) guidelines for risk adjustment.
• Assists in developing risk adjustment training and resource materials based on audit trends and ICD-10 guideline updates as needed.

Skills:

• Proficiency in reviewing and analyzing medical records for appropriate diagnosis code assignment.
• Strong critical thinking and analytical skills, particularly in identifying coding opportunities and compliance risks.
• Accuracy and attention to detail, with ability to maintain a high percentage coding accuracy.
• Ability to exercise discretion in handling confidential member information.
• Strong commitment to customer service and understanding and responding to customer needs within specific timeframes.
• Proficiency with Microsoft Word, Excel and PowerPoint or comparable software required.
• Ability to maintain productivity standards and quality benchmarks in a fast-paced environment while ensuring coding compliance.
• Assumes responsibility for professional growth and development.
• Self-motivated and able to work independently, while meeting productivity and quality benchmarks.
• Ongoing commitment to professional development, including maintaining CEUs and staying current with risk adjustment updates and coding regulations.
• Proficient in ICD-10-CM coding with a strong focus on risk adjustment and HCC coding methodologies.
• Proficient with common EMR systems e.g., Allscripts, EPIC, AthenaHealth, PracticeFusion, Medent

Knowledge:

• Knowledge of risk adjustment coding models.
• Knowledge of Medicare and Government programs.

Experience:

• 3 years' experience with CMS-HCC and HHS-HCC risk adjustment coding.
• Thorough knowledge of the CMS Medicare risk algorithm (CMS HCC) and the ACA risk algorithms (HHS HCC) and coding guidelines.
• Direct experience speaking with providers is preferred.

Education and Certifications:

• High School Diploma or GED.
• Certified Risk Adjustment Coder (CRC) credential required.
• RHIT - Registered Health Information Technologist (RHIT), Certified Professional Coder (Physician) (CPC-P) OR Certified Coding Specialist (Physician) (CCS-P) preferred.
• Coding education including understanding of proper guidelines and usage of ICD-10-CM, CPT and HCPCS
• Active nursing credential (RN or LPN) is considered a bonus.

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.

Other:

• Key Interfaces:
• Physicians, members, caregivers, health system staff, Government officials, CBC and VHP staff and management
• Ability to work within a matrix-configured work environment
• Other: Highly regulated industry. High visibility and responsibility. Strategically important position and functions with significant membership, revenue, and compliance risks.

 

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.