The Clinical Coder will perform accurate and timely coding review and validation of HCC’s through medical records. The Coder will document ICD-10-CM codes to verify that coding meets both established coding standards as well as CMS Risk Adjustment Guidelines. Once the ICD-10 codes have been documented data entry will be required to submit claims to the plans 3rd party administrator claims system for adjudication of that claim. The Clinical Coder will assist the Risk Adjustment HCC Clinical Coding Specialist with projects assigned which will include develop coding related documentation/policies specific to all Medicare & Medicaid Risk Adjustment criteria.
Will also be responsible for timely completion of projects, including timeline development & maintenance as it pertains to encounter data.
Minimum of three (3) years with demonstrated sustained coding quality
Previous experience reviewing medical records for appropriateness code assignment
Knowledge of government claims processing methodology, ICD-10 and CPT coding guidelines and knowledge State and Federal regulations
Experience in HCC coding in a managed care setting
General managed care system knowledge – claims, enrollment, provider, care management
General knowledge of state and federal regulatory requirements related to plan operations
Previous experience working in working in a managed care environment (Medicare / Medicaid)
MS Office (MS Word, Excel and Access) skills are a must
Understanding of claims processing and how that impacts encounter files
Complete appropriate paperwork/documentation/system entry regarding claim/encounter information
Demonstrate analytical and problem-solving ability regarding barriers to receiving and validating accurate HCC information