CRC Certified Medical Coder – Risk Adjustment

We are seeking an experienced medical coder with experience in US healthcare, medical coding, and risk adjustment. The role involves reviewing clinical documentation, validating diagnosis and procedure codes, accurately capturing HCCs and chronic conditions, and ensuring compliance with CMS and payer-specific guidelines.

This individual-contributor role requires strong knowledge of ICD-10-CM, CPT, HCPCS, Medicare Advantage risk adjustment, clinical documentation, and medical terminology.

Key Responsibilities

• Review and interpret inpatient, outpatient, Emergency Department, ICU, oncology, specialty, and physician-office medical records.
• Review physician notes, discharge summaries, pathology reports, imaging results, laboratory findings, treatment records, and other clinical documentation.
• Assign and validate ICD-10-CM, CPT, HCPCS, modifiers, Evaluation and Management codes, procedures, injections, and other applicable coding elements.
• Perform prospective, concurrent, and retrospective chart reviews for Medicare Advantage and risk-adjustment programs.
• Accurately identify and capture HCCs, chronic conditions, complications, comorbidities, disease severity, and burden of illness.
• Validate diagnoses using MEAT criteria, clinical indicators, treatment status, and applicable coding guidelines.
• Transcribe, edit, and proofread clinical documentation, including physician notes, consultation reports, procedure notes, discharge summaries, and diagnostic reports.
• Identify inconsistencies or missing information in transcribed clinical documents and escalate them through the appropriate clarification process.
• Identify documentation gaps, coding discrepancies, unsupported diagnoses, missed coding opportunities, and areas requiring clinical clarification.
• Draft compliant provider queries to obtain additional diagnosis specificity and improve documentation accuracy.
• Conduct coding quality reviews, risk-adjustment reviews, clinical validation, and medical-necessity checks.
• Review coding-related claim denials and identify root causes involving coding errors, documentation deficiencies, medical necessity, or payer guidelines.
• Support denial analysis, clinical appeals, audit responses, and reimbursement-accuracy activities.
• Maintain accurate records of coding reviews, identified discrepancies, provider queries, audit findings, and corrective actions.
• Analyse coding accuracy, denial trends, audit results, quality metrics, and individual productivity.
• Collaborate with coding, CDI, quality, operations, provider, clinical, AR, and analytics teams to improve documentation quality and first-pass claim acceptance.
• Support HEDIS abstraction, Star Ratings, value-based care, Medicare Advantage, and population-health initiatives when required.
• Maintain patient confidentiality and ensure compliance with HIPAA, CMS regulations, LCDs, NCDs, payer policies, and applicable coding standards.
• Stay updated on changes to ICD-10-CM, CPT, HCPCS, CMS risk-adjustment models, HCC guidelines, payer requirements, and clinical documentation standards.

Required Qualifications

• Graduate degree or relevant qualification in life sciences, healthcare, nursing, pharmacy, or a related field.
• CRC certification is required.
• Hands-on experience in Medicare Advantage risk adjustment and HCC coding.
• Strong knowledge of ICD-10-CM, CPT, HCPCS, CMS guidelines, Medicare Advantage requirements, and clinical documentation standards.
• Experience in prospective, concurrent, and retrospective medical-record reviews.
• Practical experience in medical transcription, editing, proofreading, and interpretation of clinical documentation.
• Strong knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
• Experience in identifying documentation gaps and preparing compliant provider queries.
• Understanding of coding audits, claim denials, medical necessity, clinical validation, and payer-specific requirements.
• Strong understanding of HIPAA, coding compliance, data confidentiality, and audit requirements.
• Good analytical, communication, documentation, and problem-solving skills.
• Ability to work independently while maintaining the required quality, accuracy, and productivity standards.

Pay: $25.00 - $40.00 per hour

Expected hours: 168.0 per week

Benefits:

• Flexible schedule

Experience:

• CRC HCC Risk Adjustment Coding : 3 years (Preferred)

Work Location: Remote