Professional Coder II

Horizon Healthcare Services•Newark, NJ

About The Position

The Senior Professional Coder performs code abstraction using Official Coding Guidelines for ICD-9-CM/ICD-10-CM, AHA Coding Clinic guidance, applicable state and federal regulations, and internal policies and procedures. The role supports HCC risk adjustment code abstraction for programs including Commercial Risk Adjustment/IVA (Initial Validation Audit) and Medicare Advantage Risk Adjustment/RADV (Risk Adjustment Data Validation). Coders are expected to maintain at least a 95% accuracy rating on coding quality audits. The position supports risk adjustment coding initiatives through chart review, quality assurance, staff education, analysis of coding results, and collaboration with operations, clinical leadership, management, and other departments. The company describes the role as part of a mission-driven organization focused on improving health care quality, affordability, and member experience.

Requirements

Current Registered Health Information Technologies (RHIT) credential, or certification in good standing from a nationally recognized accrediting agency such as AAPC or AHIMA.
At least 5 years of medical coding experience.
At least 5 years of experience in health insurance/quality chart audits and/or Utilization Review.
Bachelor's degree.
Proficiency in CPT-4, HCPC, and ICD-9/ICD-10 coding.
Knowledge of medical terminology and anatomy and physiology related to medical procedures, abbreviations, and terms.
Knowledge of the health care delivery system.
Ability to use a personal computer and applicable software, including proficiency in Word and Excel.
Effective verbal and written communication skills and ability to work well within a team.
Professional and ethical business practices, adherence to company standards, and commitment to personal and professional development.
Sound judgment and problem-solving skills.
Ability to ask probing questions and obtain thorough, relevant information.

Responsibilities

Compile chart review findings and statistics, analyze results, and implement action plans to improve provider performance.
Educate new staff to produce and maintain high-quality data abstraction and chart reviews.
Develop quality assurance processes to ensure the integrity of diagnoses submitted to regulatory agencies and key stakeholders.
Evaluate and improve the effectiveness of risk adjustment coding programs, policies, procedures, and workflows.
Work with interdepartmental team management to support coding initiatives related to risk adjustment programs.
Serve as a subject matter expert supporting risk adjustment coding initiatives and identifying opportunities to enhance and grow the business.
Keep management informed about changes in ICD-10 coding regulations and guidance, quality documentation, and reporting.
Work with operations and clinical leadership to identify coding and documentation improvements and promote best practices.
Conduct mock audits or surveillance activities targeting problematic diagnoses identified by CMS and internal stakeholders.
Understand and translate CPT, HCPC, and ICD-9/ICD-10 codes for HCC abstraction.
Review medical records for completeness, accuracy, and compliance with applicable coding guidelines and regulations.
Maintain department productivity and accuracy standards.