Risk Adjustment Coding Specialist

Risk Adjustment Coding Specialist

We are seeking experienced and certified medical coders to join our Special Investigation Unit (SIU) at CareFirst. This team plays a critical role in fraud detection and prevention, focusing on prepayment claim reviews.

Responsibilities:

• Review medical records and claims for coding accuracy and compliance.
• Identify potential fraud, waste, or abuse through prepayment reviews.
• Apply correct CPT, ICD, and HCPCS codes per medical and payment policies.
• Make recommendations for claim approval or denial.
• Collaborate with investigators and SIU team members.
• Utilize coding tools such as Optum or Coder Pro.

Qualifications:

• 2–3 years of medical coding experience.
• Certification required: CPC, CPMA, CCA, or COC (CPCA not accepted).
• Strong knowledge of fraud detection, claims policies, and medical policy guidelines.
• Familiarity with prepayment review workflows preferred.
• Perform risk adjustment coding primarily for Medicare Advantage plans
• Review and abstract medical records accurately
• Conduct RADV (Risk Adjustment Data Validation) coding and auditing
• Work in a high-volume, production-driven environment
• Use Microsoft Excel for basic tracking and reporting of coding data
• Ensure compliance with MEAT criteria (Monitor, Evaluate, Assess, Treat) for diagnosis validation

Qualifications:

• CRC Certification (Certified Risk Adjustment Coder) – Mandatory
• Minimum 3+ years of Risk Adjustment Coding experience
• Hands-on experience with:
  • RADV coding
  • Auditing
• Strong knowledge of:
  • ICD coding guidelines
  • Risk adjustment methodologies
• Ability to work efficiently in a production-based environment
• Basic proficiency in Microsoft Excel

Preferred Qualifications:

• CPC Certification (Certified Professional Coder) – Nice to have

Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.