RN Risk Adjustment and Coding Specialist


Capstone Performance Systems, a subsidiary or Tabula Rasa Healthcare is seeking a Risk Adjustment and Coding Specialist (Nurse Coder) who will apply his or her technical and specialized expertise to help healthcare programs remain compliant with government regulations while identifying opportunities for increased financial success.

The Nurse Coder will work from his or her home office in or near Pittsburgh, PA/St. Louis, MO area to help client PACE and other organizations optimize compliance and revenue through accurate and complete submission of diagnosis codes and ongoing analysis of Hierarchical Condition Category (HCC) risk scores. He/she will serve as liaison to Risk Adjustment clients, coordinate services to fulfill client contracts; and evaluate medical records to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual – Clinical Modification (ICD-9-CM and ICD-10-CM).  The position will assist and coordinate the data management processes required to obtain needed data from clients, load into necessary databases and produce reports.  The position will also provide technical guidance and education to medical, management and administrative staff regarding coding and medical chart review process and support client compliance with CMS rules and regulations, health plan audit requirements and coding guidelines.  Some travel is required.

A Capstone RN Risk Adjustment and Coding Specialist will:

  • Provide coordination and service support to fulfill contractual obligations to Risk Adjustment clients:
    • Assist with scheduling trainings, reviews, reports
    • Communicate with clients
    • Research and provide courteous, accurate and timely response to inquiries by providers as related to HCC Risk Adjustment projects and reports
  • Provide direct service (e.g., training, documentation reviews) for clients.
  • Audit client medical record documentation to assess accuracy in coding to fulfill regulatory requirements. When applicable, assess that submitted diagnoses are properly documented and supported within progress note according to applicable rules and regulations including but not limited to encounter date, legibility, proper provider signature and member identification requirements.
  • Support client providers in proper medical record documentation and HCC reimbursement methodology. Provide technical guidance to medical management and claims staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines; educate and advise staff on codes, documentation, procedures, and requirements; identify training needs, prepare training materials, and conduct coaching for physicians and support staff to improve skills in the review and audit of coding quality health data.
  • Perform retrospective coding reviews and other coding activities as required.
  • Facilitate client education sessions on site or via webinars.
  • Assist clients with transition to ICD-10 usage as required.
  • Support Risk Adjustment service marketing efforts.
  • Adhere to Official Coding Guidelines.
  • Review bulletins, newsletters, and periodicals, and attend workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation.

The successful candidate for this position will:

  • Hold a valid Registered Nurse or LPN license.
  • Possess valid medical coding certification, such as
    • Certified Coding Specialist designation (CCS)
    • Certified Professional Coder (CPC)
    • Certified RN Coder (CRN-C)
    • Registered Health Information Administrator (RHIA) designation is a plus
    • If not certified, an otherwise acceptable candidate must obtain certification within the first twelve (12) months of employment
  • Possess at least 3 years of nursing experience, preferably in Medicare Advantage, PACE, or other managed care environment.
  • Preferred to posses at least 3 years of experience coding ICD-9 CM, and experience in ICD-10 CM, preferably in Medicare Advantage or PACE environment.
  • Possess knowledge of: ICD-9-CM, ICD-10 and CPT coding guidelines; medical terminology; anatomy and physiology; Medicare reimbursement guidelines
  • Possess knowledge of the CMS-HCC Risk Adjustment Methodology
  • Be an intermediate to Advanced computer user:
    • Microsoft Office – Word, Excel, PowerPoint
    • Microsoft Access or other database a plus
    • File management
    • Adobe Acrobat
    • Webinar tools
    • Comfortable to access/use multiple Electronic Medical Reporting products
  • Have strong written and verbal communication skills, including propensity to establish and build strong relationships.
  • Possess strong analytical skills, with attention to detail.
  • Be a dependable self-starter who is motivated to enhance skills and knowledge base.
  • Take initiative to establish priorities, coordinate work activities and perform multiple and complex tasks while working independently under tight deadlines with minimal supervision in a remote setting.
  • Possess strong organizational, project and time management skills.
  • Be detail oriented and quick to follow instructions and learn new tasks.
  • Be customer service oriented and relate to all levels of internal and external audiences.
  • Possess a strong work ethic with impeccable integrity.

To be considered for this position, apply via email by sending an updated copy of your resume and letter of interest to Apply Here