Risk Adjustment Quality Specialist
Core
Coordinate and support prospective, concurrent, and retrospective reviews to assist with patient care management and facilitate chart retrieval for Health Plan audits.
Role type
Risk Adjustment Quality Specialist
Builds
Accurate HCC coding and documentation for value-based care contracts
Domain
Healthcare administration / Risk Adjustment
Required skills
Hierarchical Condition Categories (HCC) coding, CMS risk adjustment, medical record review, provider query management, claims processing procedures, state and federal regulations, Medicare Part D requirements, coding software utilization, analytical problem-solving
Preferred skills
Registered Nurse, Health Information Management degree, 3M Coding Solution
Responsibilities
Perform comprehensive reviews of patient medical records for documentation consistency and adequacy to identify all appropriate coding based on CMS HCC categories; Monitor revenue opportunities related to value-based care; Manage the provider query process to clarify documentation and ensure the completeness and accuracy of patient diagnoses; Utilize evidence based practices to provide providers with targeted feedback and education 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
