Registered Nurse – HCC/RAF Coding Specialist

Baystate Health • Springfield, MA

26d • Hybrid

About The Position

The HCC/RAF Coding Nurse is responsible for conducting comprehensive medical record reviews and assigning accurate ICD-10-CM diagnosis codes for risk adjustment-eligible patients. This role supports the organization's Population Health and Value-Based Care initiatives by ensuring complete, accurate, and compliant documentation of chronic conditions in accordance with Centers for Medicare & Medicaid Services (CMS) and Hierarchical Condition Category (HCC) guidelines. Working collaboratively with providers and clinical staff, the HCC/RAF Coding Nurse identifies documentation opportunities, promotes coding accuracy, improves the completeness of patient problem lists, and supports appropriate reimbursement through Medicare Risk Adjustment (RAF) and quality initiatives, including Healthcare Effectiveness Data and Information Set (HEDIS). This position also serves as a clinical coding resource by providing education and guidance to providers while improving documentation quality, patient outcomes, and provider satisfaction. This position complies with all organizational policies, regulatory requirements, and applicable federal and state laws while performing other duties as assigned.

Requirements

• Associate Degree in Nursing (ADN) required
• Current Massachusetts Registered Nurse (RN) license required
• Minimum of three (3) years of clinical RN experience required
• Valid driver's license required
• Strong clinical knowledge of chronic disease management.
• Knowledge of ICD-10-CM coding, CMS HCC guidelines, Medicare Risk Adjustment methodologies, HEDIS, and Clinical Documentation Improvement (CDI) principles.
• Exceptional analytical and critical thinking skills with the ability to interpret complex clinical documentation and coding requirements.
• Strong presentation, facilitation, and provider education skills with the ability to effectively communicate complex coding and regulatory concepts to diverse clinical audiences.
• Demonstrated ability to build collaborative relationships with providers and clinical staff through education, coaching, and consultation.
• Excellent communication, organizational, analytical, and problem-solving skills.
• Proficiency with Microsoft Office applications and electronic medical record systems.
• Ability to work independently while managing multiple priorities and maintaining high productivity, accuracy, and quality standards.
• Self-motivated with a commitment to continuous learning and maintaining current knowledge of CMS HCC, ICD-10-CM, Medicare Risk Adjustment, and related regulatory guidelines.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred
• Physician practice clinical experience may be considered.
• Experience with HCC/RAF coding, Medicare Risk Adjustment, Clinical Documentation Improvement (CDI), or Population Health preferred.
• Experience with electronic medical record systems; Cerner experience preferred.

Responsibilities

• Review medical records and assign accurate ICD-10-CM diagnosis codes in accordance with CMS HCC guidelines.
• Identify documentation gaps and collaborate with providers to clarify incomplete, conflicting, or ambiguous documentation.
• Maintain accurate patient problem lists by adding, updating, and resolving diagnoses as appropriate.
• Identify and validate chronic conditions that impact Medicare Risk Adjustment (RAF) and quality reporting.
• Educate providers and staff on HCC coding, documentation improvement, and coding best practices.
• Utilize risk adjustment reports to prioritize chart reviews, provider education, and documentation improvement efforts.
• Promote Medicare Annual Wellness Visits to support preventive care, documentation accuracy, and risk adjustment capture.
• Support clinical outcome initiatives, quality improvement projects, Population Health initiatives, and patient onboarding activities.
• Maintain compliance with organizational policies, CMS regulations, ICD-10-CM coding standards, and applicable federal and state laws.
• Perform other duties as assigned.

Benefits

• High-quality, low-cost medical, dental, and vision insurance
• Pet, home, auto, and personal insurance
• Certification and continuing education reimbursement
• 403(b) retirement plan with company match and annual company contribution increases based on years of service
• Life insurance
• Free financial coaching from a certified professional
• Reimbursement for well-being activities, including gym memberships, fitness equipment, personal training, massage, and more
• Well-being programs supporting mental, physical, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree