Job Description:

The Medicare Risk Adjustment Specialist (MRA) conducts quality assurance audits of medical records and ICD-9/10 diagnosis codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) and other government agencies. The Risk Adjustment Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Position Overview:

The Risk Adjustment Coding Specialist confirms any risk adjustment errors and findings. Coders will need to understand the basis for medical record documentation, origination from the provider of service and in alignment with dates of service, service codes and related HCC.

Duties and Responsibilities:

The Risk Adjustment Professional ensures coding is accurate and properly supported by clinical documentation within the health record. Follows state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records. May participate in provider education programs on coding compliance. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Qualifications Required:

• Must be certified Professional Coder, Certified Outpatient Coder, Claims Coders Certified Claims Specialty-Provider, Register Health Information Technology, or Registered Health Information Administrative Coding Certification required
• 2-3 years’ experience in Health Plan Operations, Managed care, or provider settings
• Proficiency in Microsoft Suite specifically Excel as well as familiarity with various EMR (Electronic Medical Records) Systems
• Extensive knowledge in medical terminology and ability to research coding related questions
• Requires advance technical knowledge in Physician, Multi – Specialty, Surgical, Hospital, Lab, Pharmacy, or other related Code Sets

Qualifications Preferred:

• Previous experience in risk adjustment coding activities in a Medicare, ACA or provider organization to include RAPs, EDPS, Edge Server, RADV Audits and all CMS, State and other regulatory Guidelines.
• Knowledge of claims coding and payment methodology, associated with a Health Plan domain
• Claims System acumen