Risk Adjustment Coder
Sentara Health
Summary
Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS).
Job description
Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits.
Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC).
Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities.
Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight.
Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding.
Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns.
Serves as subject matter expert on risk adjustment diagnosis coding guidelines.
Coordinates risk adjustment gap elimination with clinical and quality gap elimination.
Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.
Requirements
- Associate degree (Required)
- Medical Records Data - 1 year (Required)
- Coding - 2 years (Required)
- One of the following certifications are required: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
- Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment.
Benefits
- Medical, Dental & Vision
- Adoption, Fertility & Surrogacy Reimbursement
- Paid Time Off & Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term & Short-Term Disability
- Critical Illness Plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance
- Student Debt Pay Down
- Pet Insurance
- Legal Resources Plan
- Annual Discretionary Bonus
Company overview
Sentara Health is a leading not-for-profit integrated healthcare delivery system serving Virginia, northeastern North Carolina, and Florida. Founded in 1888 and headquartered in Hampton Roads, Virginia, Sentara operates 12 acute care hospitals across its service area, with 10 hospitals holding prestigious Magnet® recognition for nursing excellence. The organization employs approximately 34,000 healthcare professionals and serves over 1 million health plan members through its Sentara Health Plans division. As one of the top 20 largest not-for-profit integrated health systems in the United States, Sentara is nationally recognized for clinical quality, safety, and innovation. The system has received numerous accolades including Health Quality Innovator of the Year (2024), Forbes' "America's Best-In-State Employer" (2024), and inclusion in IBM Watson Health's "Top 15 Health Systems." Sentara's comprehensive services span hospital care, outpatient facilities, home health, hospice services, and specialized programs like the Nightingale air ambulance service, which has completed over 20,000 missions since 1982.