Risk Adjustment Coder

Position Purpose

The purpose of this position is to apply the appropriate diagnostic and procedure codes to individual patient health information for data retrieval, analysis, and claims processing for the health plan.

Nature and Scope

This position reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters covering a wide variety of clinical cases and services for risk adjustment models. This position is responsible for translating diagnostic phrases utilized by healthcare providers into coded form.

The incumbent must have the skill sets to:

· Select correct ICD code assignment by proficient analysis and translation of diagnostic statements, physicians’ orders, and other pertinent documentation.

· Critically evaluate valid encounters, including face-to-face, legibility and valid signature, per Medicare, Commercial and Federal and State requirements

· Maintain and grow the current knowledge of the Medicare and Commercial Risk Adjustment outpatient/inpatient billing systems/processes

· Facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness

· Stay current on all changes in coding conventions and coding updates

· Conduct prospective and retrospective member reviews to close care gaps

· Adhere to the coding guidelines

· Work both in a team and individual environment with minimum supervision and is confident working with a wide variety of healthcare professionals

· Consistently meet or exceed productivity and quality standards

The Incumbent must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for coding. The coder must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded.

This position does notprovide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred