Loma Linda-posted 4 months ago
Redlands, CA
5,001-10,000 employees

The Coder 1 – Risk Adjustment is responsible for concurrent, prospective, and retrospective clinical documentation review as it pertains to Risk Adjustment Data Validation (RADV) timelines, with an emphasis on completeness and accuracy of provider documentation related to severity of illness and supporting clinical care plan(s) for the validation of Hierarchical Condition Category (HCC) diagnoses. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specificity, clinical support, and/or completeness of the progress notes. Provides compliant education related to documentation integrity, completeness, and consistency. Keeps providers up to date on CMS, ICD-10-CM, AHA Coding, health plan etc. guidelines as it pertains to Risk Adjustment for the purpose of, documentation trends and opportunities for improvement related to documentation integrity. Performs other duties as needed.

  • Conduct concurrent, prospective, and retrospective clinical documentation reviews for Risk Adjustment Data Validation (RADV).
  • Ensure completeness and accuracy of provider documentation related to severity of illness and clinical care plans for HCC diagnoses.
  • Communicate with providers to clarify needs for specificity and completeness in documentation.
  • Provide education on documentation integrity, completeness, and consistency.
  • Update providers on CMS, ICD-10-CM, AHA Coding, and health plan guidelines related to Risk Adjustment.
  • Identify documentation trends and opportunities for improvement.
  • Bachelor's degree in Health Information Management or other clinical/healthcare degree preferred.
  • 2+ years overall combined clinical/medical experience.
  • At least 1+ year of Risk Adjustment coding specific experience or Clinical Documentation Improvement/Specialist equivalent.
  • Comprehensive understanding of electronic medical records and medical terminology.
  • Expertise in CMS Risk Adjustment Data Validation (RADV) for Medicare Advantage Plans.
  • Proficiency in medical coding including E/M, ICD-10, CPT, and HCC coding.
  • Certified Clinical Documentation Specialist (CCDS) preferred.
  • Equivalent combination of Risk Adjustment Coding work experience and relevant AAPC or AHIMA certification may be substituted.
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