HCC Coder/Auditor

Job Summary

The HCC Coder/Auditor reviews, codes, and audits medical records to ensure accurate risk adjustment reporting and compliance with CMS Risk Adjustment requirements, ICD-10-CM Official Coding Guidelines, and client-specific standards. This position communicates coding findings and documentation improvement opportunities to clients, leadership, and internal teams; maintains audit-ready records; supports education and quality initiatives; and completes retrospective, prospective, and other Medicare Advantage or Risk Adjustment activities as assigned.

Responsibilities

Coding, Auditing, and Quality Review

• Determine daily assignments through established department and project processes.
• Access designated client systems to review and code medical records for HCC and Risk Adjustment projects using CMS requirements, ICD-10-CM Official Coding Guidelines, and client-specific standards.
• Perform coding audits and quality reviews to validate diagnosis-code accuracy and documentation support.
• Identify undercoded, overcoded, unsupported, and missed diagnoses; document findings and provide clear oral or written coding rationale.
• Support retrospective and prospective reviews and other Medicare Advantage or Risk Adjustment activities as assigned.

Client Engagement & Documentation Improvement

• Communicate coding findings, trends, and documentation improvement opportunities to clients, management, and internal teams.
• Prepare and present client and internal education, quality, and coding presentations as requested.

Operational & Compliance Support

• Complete client spreadsheets, databases, audit tools, and other tracking documentation accurately and timely.
• Maintain established productivity and quality standards and update accurate productivity and quality records.
• Record time and project activities accurately in designated timekeeping systems.
• Follow department policies, client instructions, HIPAA requirements, confidentiality standards, and established workflows.
• Remain current on CMS Risk Adjustment regulations, RADV requirements, ICD-10-CM guidelines, Coding Clinic guidance, and relevant industry practices.
• Maintain current MARSI and client-system access and report access issues, IT concerns, and system outages through established ticket processes.
• Work weekends or holidays when required by client demands.

Quality Improvement & Education

• Participate in internal quality assurance, education, and continuous-improvement activities.
• Assist with development, editing, and periodic quality and content reviews of company school curricula, training materials, articles, and coding resources.

Other Duties

• All other duties as assigned.

Qualifications

Education/Training

• Minimum of a High School Diploma or equivalent and Certified Risk Adjustment Coder (CRC) certification through AAPC. Certification must remain current and in good standing.
• CPC, CCS, CCS-P, RHIT, or RHIA certification; Associate's or bachelor's degree in health information management or a related healthcare field preferred.

Experience

• Minimum of 5 years of medical coding experience, including at least 3 years of HCC Risk Adjustment coding and/or auditing experience.
• Experience with Medicare Advantage and CMS Risk Adjustment programs, RADV, retrospective reviews, prospective reviews, and quality assurance activities preferred.

Knowledge, Skills And Abilities

• Strong knowledge of ICD-10-CM coding guidelines, conventions, and documentation requirements supporting risk-adjusted diagnoses.
• Knowledge of CMS Risk Adjustment methodology, HCC coding principles, and medical terminology, anatomy, physiology, disease processes, and pharmacology.
• Ability to read, analyze, and interpret complex medical records and determine accurate code assignment using official guidelines.
• Ability to identify coding trends, documentation opportunities, compliance concerns, and process-improvement opportunities.
• Strong written and verbal communication skills in the English language, including the ability to explain coding rationale clearly.
• Proficiency with Microsoft Office applications, electronic health records, coding software, databases, spreadsheets, and web-conferencing tools.
• Excellent organization, attention to detail, prioritization, deductive reasoning, and ability to meet deadlines.
• Ability to work independently while maintaining productivity, quality, integrity, confidentiality, and professional-development expectations.