We are seeking a detail-oriented and experienced Coder Auditor to join our dynamic team. The ideal candidate will be responsible for ensuring the accuracy and completeness of clinical data used to support risk adjustment coding for our Medicare plan. You will work closely with healthcare providers and clinical teams to identify and mitigate documentation gaps, ultimately supporting our mission to provide exceptional care to our members.
Responsibilities:
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Audit and QC the coding team’s output for accuracy and compliance with HCC/ICD-10-CM guidelines
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Review disposition decisions
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Speak directly with providers — writing and following up on provider queries for insufficient or ambiguous documentation
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Educate providers on documentation practices that support accurate risk adjustment coding
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Serve as the escalation point for complex charts and coding questions from the coding team
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Track error patterns and trends in coding quality and report on them
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Be able to work independently as a senior-level resource
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Be comfortable owning second-level review
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Strong knowledge of HCC hierarchy, RAF methodology, and CMS risk adjustment guidelines required
Specific Knowledge, Skills, and Abilities:
- Ability to read and interpret documents, identify areas of coding gaps. Ability to speak effectively with physicians and employees of the agency.
- Ability to identify areas of over or under utilization and work with team and physician groups to develop processes to avoid
- Ability to work with team on development of processes for right-coding, appropriate utilization, and closing gaps in care
Required Education, Experience, and Licenses:
- CRC certification required
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Managed Care/Medicare Advantage experience required, dual-eligible or FIDE-SNP experience a plus
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At least 3 years’ satisfactory experience in Managed Care, desired.
