Risk Adjustment Compliance Coder

Upper Peninsula Health Plan•Marquette, MI

1d•Hybrid

About The Position

The Risk Adjustment Compliance Coder is responsible for enhancing the accuracy, quality, and integrity of coding data that supports Medicare and Medicaid reimbursement. This role conducts risk adjustment coding audits, performs compliance research, responds to coding inquiries, and serves as a subject matter expert in risk adjustment coding and compliance. The position supports Medicare and Medicaid risk adjustment programs through the development, implementation, and ongoing evaluation of program initiatives. Highly collaborative and operational in nature, this role partners closely with providers and internal stakeholders and requires strong communication, education, and relationship-management skills. This is not a traditional production-focused coding position.

Requirements

High School Diploma
Must possess and maintain an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) certification—Certified Coding Specialist (CCS), Certified Coding Specialist-Physician (CCS-P), Certified Professional Coder (CPC), or Certified Risk Adjustment Coder (CRC)
Two (2) years of experience in medical chart coding
Knowledge and understanding of medical terminology, disease process, and anatomy and physiology
Advanced knowledge and understanding of CPT coding across a wide variety of provider specialties
Excellent organizational abilities with attention to detail
Ability to effectively communicate with, and educate, clinic staff (provider, care managers, clinic quality leads, etc.)
Working knowledge of Microsoft Office (Word, Excel, Outlook)
Keyboarding proficiency
Research and analytical skills

Nice To Haves

Associate degree in business, health information processing, or related field
Certified Coding Specialist (CCS-P, CCS, CPC) and Certified Risk Adjustment Coder (CRC)
Five (5) years of experience in medical chart coding, including inpatient and outpatient settings; working knowledge of managed care and health plan standards on Risk Adjustment Coding
Knowledge of MS PowerPoint
Oriented to managed care

Responsibilities

Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
Collaborates with Risk Adjustment Analyst to develop, implement, and continually refine internal prospective and retrospective chart review programs and related risk adjustment initiatives.
Follows International Classification of Diseases (ICD)-10 guidelines for Coding and Reporting, Centers for Medicare & Medicaid Services (CMS) risk adjustment guidelines, and demonstrates knowledge of Current Procedural Terminology (CPT) coding. Understands the impact of ICD-10 coding on the CMS Hierarchical Condition Categories (HCC) risk adjustment model, and serves as the subject matter expert for risk adjustment activities.
Supports risk adjustment compliance and program integrity activities, including RADV preparedness, high-risk diagnosis review and validation, audit support, and identification and escalation of potential coding or documentation compliance concerns.
Assists with extraction of charts via remote Electronic Medical Record (EMR) access or faxed medical record request for risk adjustment initiatives.
Performs comprehensive medical record review, verifying and ensuring accuracy, completeness, specificity, and appropriateness of diagnoses codes in accordance with ICD-10 guidelines based on medical record documentation. Documents trends, observations, and potential coding or documentation improvement opportunities identified during the review process.
Maintains a comprehensive tracking and management tool to track all coding activities; generates and maintains accurate weekly, monthly, and quarterly reports of activities.
Assists with chart review encounter data submissions to CMS based on chart review findings.
Provides support during the annual retrospective chart review performed by an external party.
Identifies, develops, and delivers general and specific educational guidance to providers and clinic staff through webinars, newsletters, presentations, and other educational forums based on risk adjustment audit findings, CMS guidelines, regulatory requirements, and industry best practices.
Collaborates with internal departments, as appropriate, to carry out risk adjustment program activities to ensure integrity of diagnoses attributed to members submitted to the Michigan Department of Health and Human Services (MDHHS) and CMS by UPHP.
Collaborates with healthcare leaders, physicians, and provider office personnel to improve the accuracy and completeness of diagnosis code capture. Facilitates provider education, documentation clarification, and coding-related discussions in a professional, consultative manner to support risk adjustment and compliance objectives.
Maintains confidentiality of client data.
Performs other related duties as assigned or requested.