HCC Coder

Position Summary

The HCC Coder is responsible for reviewing patient medical records and accurately assigning ICD-10-CM diagnosis codes in accordance with applicable coding guidelines and client requirements. The coder identifies diagnoses that map to Hierarchical Condition Categories (HCCs) under the applicable HCC model while ensuring that every reported diagnosis is appropriately supported by provider documentation.

The role supports HCC coding and value-based care programs through accurate coding, prospective and retrospective chart review, documentation gap identification, HCC recapture review, provider query support, and coding quality assurance.

Core Compliance Principle: Code the documented clinical condition accurately first, then determine whether it maps to an HCC. Diagnoses must not be selected for the purpose of increasing RAF scores.

Key Responsibilities

HCC & HCC Coding

• Review medical records for accurate ICD-10-CM diagnosis coding.
• Identify diagnoses that map to applicable HCC categories using the appropriate model and model year.
• Review chronic and complex conditions for accurate documentation and specificity.
• Apply applicable hierarchy rules when evaluating HCCs.
• Ensure reported diagnoses are supported by the medical record.
• Avoid unsupported coding, inappropriate carry-forward of historical diagnoses, and assumptions based solely on prior claims or problem lists.

Prospective Chart Review

• Review member charts before scheduled provider visits.
• Review prior-year diagnoses and HCCs and identify potential recapture opportunities.
• Identify documentation and specificity gaps for appropriate provider consideration.
• Clearly distinguish suspected opportunities from confirmed diagnoses.

Retrospective Chart Review

• Review completed encounters for coding accuracy.
• Validate documented diagnoses against assigned ICD-10-CM codes and HCC mappings.
• Identify missed, incorrectly coded, or unsupported conditions.
• Document coder findings and disposition.

Documentation & Provider Query Support

• Review assessment and plan, current clinical status, treatment plan, medications, diagnostic results, specialist documentation, relevant history, and problem lists when appropriate.
• Apply documentation-review concepts such as MEAT (Monitor, Evaluate, Assess/Address, Treat) within organizational policy and applicable coding requirements.
• Identify documentation requiring legitimate clarification and prepare compliant, non-leading provider queries.
• Track responses and update coding only after appropriate documentation or clarification.
• Never encourage documentation of a diagnosis merely to increase HCC or RAF.

Coding Quality & Compliance

• Follow applicable ICD-10-CM Official Guidelines for Coding and Reporting and current client, payer, and HCC coding requirements.
• Participate in internal coding audits and corrective education.
• Maintain required coding accuracy, turnaround times, and a clear audit trail.
• Escalate compliance concerns to the Coding Lead or Compliance team.

Required Qualifications

• Graduate or equivalent healthcare/coding education preferred.
• Medical coding, life science, nursing, pharmacy, allied-health, or related background preferred.
• CPC, CRC, CCS, COC, CCS-P, or equivalent recognized coding certification preferred.
• CRC or demonstrated HCC coding experience strongly preferred.
• 2+ years of medical coding experience preferred, including HCC/risk adjustment, Medicare Advantage, ICD-10-CM, chart review, coding audits, or value-based care.

Required Knowledge & Skills

• Strong knowledge of ICD-10-CM coding, HCC coding concepts, RAF concepts, chronic-condition coding, clinical terminology, and medical-record documentation.
• Understanding of HCC hierarchies, prospective and retrospective review, provider query processes, and coding compliance.
• Ability to navigate EMR/EHR systems and work with Microsoft Excel and reporting tools.
• Excellent attention to detail, analytical skills, written communication, independent working ability, and compliance-focused decision making.

Coder Should

✅ Code only diagnoses supported by provider documentation.
✅ Use the correct ICD-10-CM code, model year, and HCC mapping.
✅ Apply hierarchy rules and query appropriately when clarification is required.
✅ Maintain an auditable record of coding decisions.

Coder Should Not

❌ Code a diagnosis solely because it increases RAF.
❌ Automatically carry forward prior-year HCCs.
❌ Convert a suspected condition into a confirmed diagnosis.
❌ Assign greater disease severity without documentation.
❌ Change provider documentation or encourage documentation solely for financial benefit.

Work Location: In person