Risk Adjustment Coder

The Risk Adjustment Coder is responsible for reviewing and accurately assigning diagnosis codes to medical records in accordance with ICD-10-CM coding guidelines, CMS-HCC Risk Adjustment methodologies, and client-specific requirements. This role ensures complete and compliant documentation to support accurate risk score capture while maintaining high standards of coding quality, productivity, and regulatory compliance.

Key Responsibilities

• Review outpatient and physician medical records to identify and assign accurate ICD-10-CM diagnosis codes.
• Apply CMS-HCC Risk Adjustment coding guidelines and ensure proper Hierarchical Condition Category (HCC) capture.
• Validate medical documentation to ensure diagnoses are fully supported and compliant with coding standards.
• Maintain coding accuracy while meeting productivity and quality benchmarks.
• Stay current with annual ICD-10-CM, CMS-HCC, and regulatory guideline updates.
• Participate in internal and external coding audits and implement corrective actions when necessary.
• Collaborate with Quality Assurance, Clinical Documentation Improvement (CDI), providers, and Operations teams to resolve coding-related questions.
• Maintain confidentiality and comply with HIPAA, client policies, and company standards.
• Complete assigned coding tasks within required turnaround times.
• Participate in training, calibration sessions, and continuous improvement initiatives.

Qualifications

• Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Occupational Therapy, or any allied health-related course is preferred.
• Active coding certification such as CPC, CRC, CCS, CIC, or equivalent is preferred (CRC is highly preferred for Risk Adjustment coding).
• Minimum of 1–2 years of Risk Adjustment coding experience.
• Strong knowledge of:
  • ICD-10-CM coding guidelines
  • CMS-HCC Risk Adjustment methodology
  • Hierarchical Condition Categories (HCC)
  • Medical terminology, anatomy, physiology, and disease processes
  • Documentation requirements for accurate diagnosis capture
• Experience working with Electronic Health Records (EHR) and coding software.
• Strong analytical, critical thinking, and problem-solving skills.
• Excellent attention to detail with the ability to consistently meet quality and productivity goals.
• Good written and verbal communication skills.
• Ability to work independently and manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Certified Risk Adjustment Coder (CRC) credential.
• Experience with Medicare Advantage Risk Adjustment coding.
• Familiarity with RADV audits, provider education, and documentation improvement initiatives.
• Previous experience in a healthcare BPO or outsourcing environment is an advantage.

Key Competencies

• ICD-10-CM Coding
• CMS-HCC Risk Adjustment
• Medical Record Review
• Clinical Documentation Validation
• Quality & Compliance
• Productivity Management
• Attention to Detail
• Critical Thinking
• Time Management
• Collaboration & Communication