**Resp & Qualifications** **PURPOSE:** The Risk Adjustment Coding Specialist supports prospective risk adjustment via concurrent review and supplemental data CMS filing, HHS-Risk Adjustment Data Validation (RADV) audit and any other chart coding functions, by performing moderately complex medical record review and coding, ensuring compliance with all applicable Federal, State and/or County laws and regulations related to coding and documentation guidelines. The development and ongoing maintenance of the Commercial Risk Adjustment Coding guidelines, as well as, guiding junior coding specialists are included in the job responsibilities. **ESSENTIAL FUNCTIONS:** + Verifies accuracy, completeness, and appropriateness of diagnosis codes with provider partnerships based on medical documentation provided at all levels of complexity. Utilizes appropriate coding guidelines and recommends any changes to diagnosis codes based on chart review. Achieves and maintains coding accuracy levels greater than 90%. Works with vendors, providers and hospital staff to coordinate record access. + Identifies and documents coding observations or discrepancies and provides information to management team to further enhance quality and/or provider education. Work with leadership and third-party vendors to negotiate agreement on complex medical record diagnoses and determine compliance with coding guidelines which will be accepted by the federal government. Develops and conducts new physician/other healthcare practitioner coding orientation/education, including group or individual sessions. Develop and maintain coding guidelines for Commercial Risk Adjustment, maintaining those guidelines for any changes in industry standards. + Provide guidance and direction to Coding Specialists for concurrent review of CareFirst members when validating complex medical records to help guide in determining appropriate coding. **SUPERVISORY RESPONSIBILITY:** Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources. **QUALIFICATIONS:** **Education Level:** Associate's Degree in Health Information Technology, Business or related field OR in lieu of a Associate degree, an additional 2 years of relevant work experience is required in addition to the required work experience. **Licenses/Certifications:** + CCS-Certified Coding Specialist or CPS, CCS-P, CRC Upon Hire Required or + RHIT - Registered Health Information Technician or RHIA Upon Hire Preferred **Experience:** 3 years risk adjustment/hierarchical condition category (HCC) coding experience. **Knowledge, Skills and Abilities (KSAs)** + Adobe Acrobat Professional. + Microsoft Word, Excel, Outlook, Claims Processing Facets. + Ability to adapt to various coding technology platforms, such as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems and coding documentation platforms. + Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. + Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. **Salary Range:** $49,176 - $90,156 **Travel Requirements** **Estimate Amount:** 5% medical sites to supervise medical record retrieval, conferences **Salary Range Disclaimer** The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). **Department** Risk Adjustment **Equal Employment Opportunity** CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. **Where To Apply** Please visit our website to apply: www.carefirst.com/careers **Federal Disc/Physical Demand** Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. **PHYSICAL DEMANDS:** The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. **Sponsorship in US** Must be eligible to work in the U.S. without Sponsorship \#LI-NH2 REQNUMBER: 20116