Medical Coding Specialist

The HCC Coding Specialist will be responsible for partnering with providers and clinic operations staff to support the High Desert PACE (HDP) Revenue Cycle with a primary focus on hierarchical condition category (HCC) coding to optimize risk adjustment factor (RAF) scores. The Coding Specialist is responsible for understanding and optimizing the revenue cycle through accurate and specific diagnostic coding. This includes maintaining a comprehensive understanding of HCC coding methodology, CMS risk adjustment models, and ensuring accurate documentation to support assigned codes. The Coding Specialist provides critical support to providers and clinic staff for diagnostic specificity in ICD-10-CM coding, with particular emphasis on chronic conditions impacting risk scores. The specialist serves as a liaison between the delivery sites and compliance operations to support the Provider Services Monitoring Program and related educational activities around HCC coding, compliance, and RAF score optimization.

• Ensures all diagnoses are coded to the highest level of specificity and accurately captured in the medical record to optimize RAF scores.
• Reviews clinical documentation to identify all reportable HCC diagnoses that impact risk adjustment.
• Conducts one-on-one chart reviews with each provider to ensure complete and specific diagnosis coding.
• Performs prospective, concurrent, and retrospective reviews to identify potential documentation gaps for HCC-relevant conditions.
• Develops in-depth understanding of EHR in the areas of diagnosis entry, charting tools, and documentation requirements for HCC validation.
• Reviews each provider's individual charting tools and preference lists to ensure accurate ICD-10-CM coding with emphasis on conditions that impact risk scores.
• Creates and maintains provider-specific "gap lists" of previously documented chronic conditions requiring annual documentation.
• Analyzes patient records to identify opportunities for accurate and compliant RAF score improvement.
• Provides feedback to each provider based on identified coding trends and opportunities for documentation improvement.
• Implements changes and provides education to providers, departments, and clinics with regard to optimizing HCC capture and risk adjustment scores.
• Provides coding education (ICD-10-CM, HCC, and risk adjustment methodology) to providers and clinical staff in accordance with established corporate compliance plan.
• Works with providers to implement corrective action plans when documentation issues are identified.
• Actively trains physicians and other providers on proper documentation to support HCC diagnosis coding.
• Conducts regular audits to ensure documentation supports submitted diagnoses and meets CMS requirements.
• Monitors changes to CMS HCC models and updates coding practices accordingly.
• Attends clinic and department staff meetings to disseminate information and become familiar with operational issues.
• Implements corrective action plans to improve revenue cycle outcomes related to risk adjustment.
• Creates site-specific education and partners with department directors to implement site-specific revenue improvement projects.
• Adheres to and supports the center's practices, procedures, and policies, including assigned break times and attendance.
• Accepts assigned duties in a cooperative manner and performs all other related duties as assigned.
• Maintains flexible schedule of hours worked.
• May require use of personal vehicle.

Education & Training

• Certified Professional Coder (AAPC) or Certified Coding Specialist certification (AHIMA) required.
• Risk Adjustment Coding certification (CRC, CPRC, or similar) preferred.
• Minimum 2 years of experience in risk adjustment or HCC coding strongly preferred.
• 1 years of experience as a certified coding specialist required.
• Thorough knowledge of CMS HCC risk adjustment model and RAF scoring methodology.
• Proficiency in medical record documentation review with focus on chronic condition documentation.
• Experience with CMS Evaluation and Management Documentation Guidelines.
• Understanding of CMS Risk Adjustment Data Validation (RADV) requirements.
• Knowledge of CMS Correct Coding Initiative.
• Familiarity with Third Party Payer Reimbursement Policies and Procedures.
• Two years working with coding systems.
• Two years previous experience in medical record chart documentation review.
• Two years' experience in group education with provider audiences.
• Experience in PACE program setting preferred.

Skills & Abilities

• Maintains current knowledge of regulations and legislation regarding HCC coding, risk adjustment, and compliance issues.
• Demonstrated ability in critical thinking, self-initiative, and self-direction.
• Ability to analyze documentation for appropriate HCC capture opportunities.
• Excellent skills in data analysis to identify patterns and improvement opportunities in coding practices.
• Ability to present information in one-on-one and group settings.
• Strong communication skills to effectively educate providers on documentation requirements.
• Ability to communicate information in a professional and confident manner.
• Demonstrates a thorough understanding of the front and back-end revenue cycle components in a physician practice.
• Understanding of physiology, medical terminology, and disease processes is required.
• Familiarity with PACE program requirements and Medicare risk adjustment models.
• Proficiency in Microsoft Word, Excel, and Access.
• Strong analytical skills to identify coding patterns and opportunities for improvement.
• Ability to maintain strict confidentiality of patient and organizational information.

Working Conditions

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Primarily work indoors.
• Usually have their own office or a shared office space
• Are exposed daily to participants who have diseases or infections.
• Wear protective clothing such as gown, masks and gloves, as needed
• Work very close to others, especially when examining participants
• While performing the duties of this job, the employee is frequently required to walk, sit, and/or stand
• The employee must occasionally lift and/or move up to 25 pounds.