Risk Adjustment Coder

Job Description

Job Description

Primary Purpose:

Support the risk and quality team, IPA Administrators, and the VP of Operations on Clinical Initiatives to improve patient outcomes and group quality measures in Risk Adjustment, CMS 5 Star, and the commercial and Medi-Cal programs.

Principal Duties and Responsibilities (* = essential functions):

• Outreach and coordinate care for IPA members who need preventative and/or chronic care services such as mammograms, colonoscopies, uncontrolled HbA1c, uncontrolled blood pressure, etc.
• Collaborate with Risk Adjustment and quality on provider education.
• Maintain knowledge of clinical initiatives and risk adjustment program requirements 
• Maintain knowledge of 5 Star performance and risk adjustment factors for all IPAs.
• Collaborate with health plans on 5 Star, commercial, and Medi-Cal gap reports.
• Coordinate outreach to PCP offices on member due reports, including the No Annual Visits list.
• Provide PCP offices with ongoing education on quality measures
• Work with health plans to provide supplemental data 
• To contribute to a fair and positive work environment. *
• To perform other duties as assigned. 
• Review, monitor, and track medical record retrieval reports to identify provider issues, including but not limited to refusals to comply with medical record requests.
• Identify and follow through on potential issues affecting the Risk Adjustment project

Job Specifications (KSAs):

• Requires at least two years of Risk Adjustment coder experience.
• Requires knowledge of managed care processes, generally acquired through 1 or more years of experience in a Health Plan, IPA, or Medical Group environment.
• Requires the ability to communicate clearly and effectively, verbally and in writing, with internal and external customers.
• Requires an understanding of medical terminology, generally acquired through a relevant course or 2 years or more in a medical office setting or utilization management department.
• Requires fast, accurate typing skills and proficiency in computer software, including Word and Excel

• Consistently produces accurate and timely work as it relates to departmental goals.
• Demonstrates high reliability through consistent punctuality and attendance.
• Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.
• Uses sound judgment in time management and prioritizing work to balance multiple tasks and meet required timeframes for all administrative activities.
• Demonstrates excellent interpersonal skills as discerned through observation and team project successes.
• Accurately interprets and applies departmental policies and procedures using sound judgment.
• Communicates clearly, professionally, and respectfully to peers, superiors, subordinates, and clients.
• Provides constructive feedback on assigned work projects.
• Demonstrates overall professionalism in attitude, demeanor, and personal appearance

The hourly range is $25.00 to $30.00.