Risk Adjustment Coder (Hybrid)

About the Role

This role focuses on the Risk Adjustment process that supports the documentation of acuity diagnoses for the Managed Care (MC) patient population and required activities for submission of records to Medicare Advantage (MA) payers under established capitated contracts. It assists with medical record reviews for HCC diagnoses, correct usage of various coding guidelines (ICD-10-CM, CPT, HCPCS) and federal and MA payor regulations, as well as clinical validation of appropriate supporting documentation.

Responsibilities

• Maintain compliance with Gonzaba Medical Group policies, Official Coding Guidelines, and the Gonzaba Medical Group Coder’s Pledge.
• Provide queries or technical guidance to physicians, clinical staff, and other departmental staff to identify and resolve issues or errors, such as incomplete or missing records, ambiguous documentation, or non-conforming codes.
• Accurately validate and abstract diagnosis codes from provider documentation in the patient medical record to ensure reported ICD-10 codes are appropriately supported.
• Select correct ICD-10-CM (diagnostic), CPT (procedural), and HCPCS codes based on interpretation of office visit documentation, correct coding principles, and clinical validation, with a focus on accurate capture of all supported HCC diagnosis codes.
• Remain up to date on all coding changes and usage.
• Assess qualifying notes for completion and/or identification of deficiencies; communicate with providers/staff on elements to be addressed to ensure timely processing.
• Perform review of Risk Adjustment audits for accuracy and data entry into the EMR.
• Utilize nursing and coding knowledge to assist with review activities, including re-review of audit findings to ensure accuracy in documented HCC diagnoses and ICD-10 coding, and review of payer denial/rejection reports to identify areas for provider education.
• Complete required electronic forms for submission of applicable acuity diagnosis codes based on scheduled appointments.
• Participate in other Managed Care projects, including marketing events and the Medicare Open Enrollment period.
• Review reports to identify areas for improvement or needed action to meet departmental goals.
• Support team members in all aspects of the Risk Adjustment process to ensure defined timelines and departmental goals are met.
• Adhere to all confidentiality and HIPAA requirements as outlined in Gonzaba Medical Group Operating Policies and Procedures.
• Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers, including in-person and virtual communication (via telephone or telehealth applications).
• Perform other duties as assigned.

Requirements

• All duties must be performed accurately and in a timely manner.
• Assume responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
• Adhere to customer service expectations in all communications.