Risk Adjustment Quality Specialist
Core
Coordinate and support prospective, concurrent, and retrospective reviews to assist with patient care management and validate medical record data for HCC coding.
Role type
Risk Adjustment Quality Specialist
Builds
Health Plan audits and reports
Domain
Healthcare administration / Risk Adjustment / Value-based care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Hierarchical Condition Categories (HCC) coding, CMS risk adjustment knowledge, claims processing procedures, state and federal regulations, Medicare Part D requirements, coding software utilization, provider query management, performance data analysis
Preferred skills
Registered Nurse, Health Information Management degree, 3M Coding Solution knowledge
Responsibilities
Perform comprehensive reviews of patient medical records for documentation consistency and adequacy to identify appropriate HCC coding; Monitor revenue opportunities related to value-based care; Manage the provider query process to clarify documentation and ensure completeness of patient diagnoses; Utilize evidence-based practices to provide providers with targeted feedback on improving documentation and coding accuracy; Analyze performance data to identify trends, gaps, and opportunities for improvement; Collaborate with medical staff to clarify documentation and support accurate coding and reimbursement; Participate in audits, quality reviews, and continuous improvement initiatives; Educate staff on coding practices and HCC assignments
Seniority
Mid-level, hands-on IC
