Senior Medical Coder

The HCC Coder is responsible for reviewing and analyzing patient medical records to assign accurate ICD-10-CM diagnosis codes in accordance with CMS-HCC (Hierarchical Condition Category) risk adjustment guidelines. The role focuses on ensuring proper documentation, compliance, and accurate Risk Adjustment Factor (RAF) scoring for reimbursement purposes.

Key Responsibilities:

1. Medical Coding & Review
• Review patient medical records including outpatient, inpatient, and home health documentation.
• Assign accurate ICD-10-CM codes based on clinical documentation.
• Map diagnosis codes to appropriate HCC categories.

2. Risk Adjustment (HCC) Coding
• Perform coding for risk adjustment projects following CMS guidelines.
• Ensure accurate capture of chronic and high-risk conditions impacting RAF scores.
• Apply knowledge of disease hierarchy and HCC models.

3. Documentation Validation
• Ensure all coded diagnoses meet MEAT (Monitor, Evaluate, Assess, Treat) criteria.
• Identify incomplete or insufficient documentation.
• Avoid unsupported, suspected, or rule-out diagnoses.

4. Quality & Compliance
• Adhere to CMS-HCC coding guidelines and ICD-10-CM standards.
• Maintain high coding accuracy and quality benchmarks.
• Participate in internal and external audits.

5. Productivity Management
• Meet daily coding targets and turnaround time (TAT).
• Maintain a balance between productivity and accuracy.

6. Collaboration
• Work closely with QA teams, auditors, and team leads.
• Address feedback and improve coding performance.

7. Continuous Learning
• Stay updated with annual ICD-10-CM changes and CMS-HCC model updates.
• Participate in training and skill enhancement programs.

Eligibility Criteria:

Education:
• Bachelor’s degree in Life Sciences, Nursing, Pharmacy, or related field
• Medical coding certification or diploma preferred

Certification:
• CPC / CCS / CRC (preferred)

Experience:
• Minimum 1–2 years of experience in medical coding
• Prior experience in HCC or risk adjustment coding preferred

Required Skills:
• Strong knowledge of ICD-10-CM coding guidelines
• Understanding of HCC, RAF, and CMS regulations
• Good knowledge of medical terminology and anatomy
• Ability to analyze and interpret clinical documentation
• High attention to detail and accuracy
• Good communication and teamwork skills

Work Environment:
• Work mode: Office-based
• Industry: US Healthcare (RCM & Risk Adjustment)
• Performance-driven and quality-focused environment

Key Performance Indicators (KPIs):
• Coding accuracy
• Productivity (charts per day)
• Compliance adherence
• Audit scores