Certified Risk Adjustment Medical Coder (CRC)

Certified Risk Adjustment Medical Coder (CRC)

Our client is seeking an experienced Certified Risk Adjustment Medical Coder (CRC) to support CMS and HHS Risk Adjustment Data Validation (RADV) audits. This position is responsible for reviewing inpatient and outpatient medical records to validate Hierarchical Condition Categories (HCCs) while ensuring compliance with CMS documentation standards, ICD-10 coding guidelines, and regulatory requirements.

The ideal candidate will have extensive experience performing CMS and HHS RADV audits, vendor-side coding reviews, and risk adjustment auditing while maintaining exceptional coding accuracy and productivity standards.

Key Responsibilities

• Review inpatient and outpatient medical records to validate HCC diagnoses.
• Determine whether submitted diagnosis codes meet CMS and HHS documentation requirements.
• Ensure documentation satisfies M.E.A.T. (Monitor, Evaluate, Assess, Treat) criteria.
• Perform coding reviews using ICD-10 Official Coding Guidelines and AHA Coding Clinic guidance.
• Support CMS Contract-Level RADV, HHS RADV, and IPM audit activities.
• Maintain a minimum of 95% coding accuracy while meeting productivity expectations.
• Research coding questions and provide recommendations for complex or unusual coding scenarios.
• Review unlisted procedure codes and identify more appropriate coding alternatives when applicable.
• Support Claims and Provider Relations teams by resolving coding-related issues.
• Maintain coding resources, documentation libraries, and HIPAA code updates.
• Serve as a coding subject matter expert for internal stakeholders.
• Maintain compliance with HIPAA and all applicable coding regulations.

Required Qualifications

• Certified Risk Adjustment Coder (CRC) certification through AAPC or AHIMA (Required)
• Bachelor's degree or equivalent professional experience
• 5+ years of professional medical coding experience
• 5+ years of risk adjustment auditing experience focused on CMS and HHS RADV reviews
• Prior experience performing:
  • CMS Contract-Level RADV audits
  • HHS RADV audits
  • IPM audits
  • Vendor coding reviews
• Strong knowledge of:
  • Hierarchical Condition Categories (HCC)
  • ICD-10 Official Coding Guidelines
  • AHA Coding Clinic
  • CMS RADV Medical Reviewer Guidance
  • Medicare Advantage
  • Affordable Care Act (ACA) lines of business
• Intermediate to advanced Microsoft Excel skills
• Ability to consistently achieve 95%+ coding accuracy
• Strong analytical, organizational, and communication skills
• Ability to work independently in a remote environment

Preferred Qualifications

• Experience supporting Claims or Provider Relations teams
• Knowledge of insurance claims processing
• Experience researching complex coding scenarios and regulatory guidance