Risk Adjustment Quality Specialist

Risk Adjustment Quality Specialist

The Risk Adjustment Quality Specialist plays a vital role in coordinating and supporting prospective, concurrent, and retrospective reviews to assist with patient care management. The position provides education and facilitates chart retrieval for Health Plan audits and reports. This position requires a comprehensive understanding of Hierarchical Condition Categories (HCC) coding to accurately translate, input, extract, and validate medical record data.

This role assists with monitoring quality program performance, including tracking, reporting, and implementation of best practices and program requirements.

• Perform comprehensive reviews of patient medical records for documentation consistency and adequacy to identify all appropriate coding based on Centers for Medicare & Medicaid Services (CMS) HCC categories.
• Monitor revenue opportunities related to value-based care.
• Manage the provider query process to clarify documentation and ensure the completeness and accuracy of patient diagnoses, particularly related to chronic conditions.
• Utilize evidence based practices to provide providers with targeted feedback and education on improving documentation and coding accuracy, specifically related to HCC.
• Demonstrate analytical and problem-solving ability with regard to barriers in receiving and validating accurate HCC information.
• Analyze performance data to identify trends, gaps, and opportunities for improvement.
• Maintains intermediate to advanced understanding of claims processing procedures, state and federal regulations, and Medicare Part D requirements.
• Utilize coding software to ensure compliance with Medicare, Medicaid, and other payer requirements.
• Collaborate with medical staff to clarify documentation and support accurate coding and reimbursement.
• Participate in audits, quality reviews, and continuous improvement initiatives.
• Educate staff on coding practices and HCC assignments.
• Maintain compliance with policies, procedures, and continuing education requirements.
• Performs other duties as needed or assigned.

Required:

• Minimum of 3 years of experience in medical coding or risk adjustment with a focus on Hierarchical Care Conditions, value based care contracts, and accountable care organizations.
• Strong knowledge of CMS risk adjustment and quality initiatives, including Hierarchical Condition Categories (HCCs).
• Completion of one of the following through AHIMA accredited programs: Certificate Coding Associate, Certificate Coding Specialist, Certified Professional Coder, Registered Health Information Technician, Registered Health Information Administrator OR
• Credentialed through AAPC

Preferred:

• Registered Nurse
• Associates or Bachelor's Degree in Health Information Management
• 3M Coding Solution Knowledge

Remote Work/Work-from-Home:

This position has hybrid work flexibility. This person must live within Kansas or Missouri, and will be required attend on-site meetings, as scheduled.

Our Cultural Beliefs

• People First
• Integrity Matters
• Better Together

At LMH Health, we value inclusion and diversity. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.