Risk Adjustment Coder

Risk Adjustment Coder



Full time

Position: Risk Adjustment Coder

Department: Clinical Documentation

Schedule: Full Time


The Risk Adjustment Coder determines the appropriate ICD10-CM diagnoses codes based on clinical documentation that follows the Official Guidelines for Coding and Reporting and Risk Adjustment guidelines for risk adjustment and Hierarchical Condition Categories (HCC). Risk adjustment coding relies on ICD-10-CM coding to assign risk scores to patients. The incumbent reviews retrospective medical record documentation and ensures that the codes are appropriately assigned. The outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/complexity of the patient while providing specific and complete information to be utilized in coding, profiling and outcomes reporting of both the facility and the physicians. The Risk Adjustment Coder utilizes standards of compliance, specifically in OP compliant query processes and clinical knowledge to identify opportunities and to achieve results Also required is advanced knowledge of CPT, ICD-10-CM, and HCPCS coding systems.



High school diploma or equivalent medical coding education. Associates Degree preferred (or direct work experience equivalent to at least 2 years)


Coding Certification from American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) is required. Certification may include Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC) and/or Certified Clinical Documentation Specialist- Outpatient or Certified Documentation Expert Outpatient (CDEO) Certified Coding Specialist (CCS), or Certified Coding Specialist Physician-Based (CCS-P), or a Certified Coding Associate (CCA), or Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) required


Minimum of two (2) years progressive coding experience in multiple specialties, HCC Risk adjustment Coding


  • Willing to work as a team innovation and collaboration is a priority
  • Experience with an Electronic Medical Record (EMR), EPIC preferred
  • Knowledge of AHA coding guidelines and methodologies: HCCs and other RA methodologies, ICD-10-CM coding guidelines, Office of Inspector General (OIG) and Federal and State regulations
  • Extensive knowledge of medical terminology, anatomy, and pathophysiology, pharmacology, and ancillary test results
  • Strong organization and analytical thinking skills detail oriented
  • Proficient with Microsoft Office applications (Outlook, Word, Excel)
  • Demonstrates critical thinking skills, able to assess, evaluate, and teach
  • Self-motivated and able to work independently without close supervision
  • Strong communication skills (interpersonal, verbal and written)
  • Medical Record audits and review
  • Familiarity with the external reporting aspects of healthcare
  • Familiarity with the business aspects of healthcare, including prospective payment systems
  • Proficient with computer applications (MS Office etc.), Excellent data entry skills
  • Strong knowledge of health records, computerized billing and charging systems, Microsoft applications, data integrity, and processing techniques required.
  • Excellent organizational skills, including ability to multi-task, prioritize essential tasks, follow-through and meet timelines.
  • Ability to work with accuracy and attention to detail
  • Ability to solve problems appropriately using job knowledge and current policies/procedures.
  • Ability to work cooperatively with members of the healthcare delivery team and staff, ability to handle frequent interruptions and adapt to changes in workload and work schedule and to respond quickly to urgent requests.
  • Must be able to maintain strict confidentiality of all personal/health sensitive information and ensure compliance of HIPAA rules and regulations.


  • Review documentation available in the Medical Record to facilitate workflows that support the clinical picture/severity of illness/complexity of the patient care rendered to patients.
  • Reviews medical records to ensure accurate codes are applied to the encounter.
  • Utilize available encoder, grouper software, and other coding resources to determine the appropriate ICD-10-CM diagnosis codes mapped to HCCs or other RA methodologies
  • Actively participate in and maintain coding quality and productivity processes
  • Collaborates with nursing or coding staff on retrospective medical record review for severity, accuracy, and quality issues.
  • Ensure documentation in the medical record follows the official coding guidelines, internal guidelines and the
  • AHIMA/ACDIS physician query brief.
  • Create and analyze reports for coding improvement trending and high-level dashboards for ongoing monitoring and opportunities.
  • Provide ongoing feedback to physicians and other providers regarding coding guidelines and requirements.
  • Assist with educational in-services for physicians, other providers, and clinic staff relating to coding and documentation compliance as well as new policies and procedures related to billing.
  • Participate in training new coding staff, as needed.