Medical Coding Specialist

Medical Coding Specialist Overview

• The Medical Coding Specialist will ensure accurate risk adjustment coding for Medicare plans.
• Collaborate with healthcare providers to address documentation gaps and enhance coding accuracy.
• Conduct audits and quality control checks on coding outputs for compliance with HCC/ICD-10-CM guidelines.
• Serve as a senior-level resource, providing second-level reviews and addressing complex coding issues.
• Educate providers on documentation practices to support accurate risk adjustment coding.
• Track error patterns and trends in coding quality, reporting findings to improve processes.
• Work independently to ensure compliance with CMS risk adjustment guidelines and RAF methodology.
• Support the organization’s mission to provide exceptional care to members through accurate coding practices.

Medical Coding Specialist Key Responsibilities & Duties

• Audit coding team outputs for accuracy and compliance with HCC/ICD-10-CM guidelines.
• Review disposition decisions and follow up on provider queries for ambiguous documentation.
• Educate providers on documentation practices supporting risk adjustment coding accuracy.
• Serve as the escalation point for complex charts and coding questions from the team.
• Track coding error patterns and trends, reporting findings to improve quality.
• Develop processes for right-coding, appropriate utilization, and closing gaps in care.
• Collaborate with physician groups to address areas of over or under utilization.
• Ensure compliance with CMS risk adjustment guidelines and RAF methodology.

Medical Coding Specialist Job Requirements

• Associate of Applied Science (AAS) degree required.
• CRC certification mandatory; dual-eligible or FIDE-SNP experience preferred.
• Minimum of 2 years of experience; 4 years preferred in Managed Care/Medicare Advantage.
• Strong knowledge of HCC hierarchy, RAF methodology, and CMS risk adjustment guidelines.
• Ability to read and interpret documents, identifying coding gaps effectively.
• Proficiency in educating providers on documentation practices for accurate coding.
• Experience in developing processes for right-coding and closing care gaps.
• Comfortable working independently and owning second-level review responsibilities.