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Medical Risk Adjustment Coder (PAL) - Orlando Health Care Coordination - Day Shift


Medical Risk Adjustment Coder (PAL) - Orlando Health Care Coordination - Day Shift - Orlando Health Heart Institute

The MedicalRisk Adjustment Coder supports the physician practices and the CareCoordination Department with Coding Improvement activities using variousclinical data systems.


High SchoolDiploma or equivalent.


Must maintain current one ofthe following:

  • CertifiedProfessional Coder (CPC)

  • Certified RiskAdjustment Coder (CRC)


Prior HCC/HHS experience withMedicare Risk Adjustment with two (2) years experience in medical coding.

Computer literate with skillsin Windows, Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

Excellentwritten and verbal communication skills; ability to write concisely andeffectively when communicating with providers.

Essential Functions

Collaborates with a variety of internal and external clients, including healthcare executives, physicians, provider office personnel, and payerrepresentatives from various health plans to streamline and optimize accuratediagnosis code capture.

Maintains responsibility for conducting clinical chart and patient billingaudits for the purpose of

Identifying and validating reported diagnoses for Medicare/Medicare Advantageand ACO health plan members.

Reviews medical records and billing history to determine if specific diseaseconditions were correctly billed and documented.

Adheres to all official coding rules and CMS guidelines for risk adjustment,and ensures accuracy,

Completeness, specificity and appropriateness of diagnosis information.

Assists with the completion of HEDIS chart reviews and facilitates the accurateand timely reporting of quality measures. .

Demonstrates analytical and problem-solving ability in the process of reviewingsubmitted

Diagnosis codes, comparing to actual services provided to the patient, and communicatesappropriate feedback to providers and billing personnel.

Performs analysis and focused chart reviews for targeted provider educationtraining projects.

Assists in the acquisition, development and distribution of coding anddocumentation improvement educational materials.

Provides articles for the quarterly coding newsletter.

Facilitates collection, validation, distribution and follow-through support ofmonthly and quarterly HCC coding reports for all providers participating in theManaged Medicare Program and Accountable Care Organization Programs.

Places emphasis on compliance with Risk Adjustment procedures and protocol,internal controls, and maintaining the highest level of workplace behavior.

Coordinates data collection and aggregation on a variety of focused audits andHCC coding capture projects.

Validates the results of payer audits and translates findings into educationalopportunities and tools to optimize revenue recovery.

Offerssupport in the Care Coordination Department, focusing on provider and staffeducation.

Facilitates ongoing quality metrics monitoring & assists with providingquarterly quality metrics reports for each PCP.

Performs data validation and integrity functions in a variety of systemspertaining to patient care, clinical documentation, charge entry & billing,and payer claims management.

Documents and reports activities regarding program status.

Reviews, analyzes and modifies data as necessary to meet both internal andexternal customer needs.

Works with clinical staff to analyze reports and collaboratively identifyimprovement opportunities.

Monitors quality, cost and efficiency on a recurring basis.

Remains available when needed to attend Managed Medicare meetings, recordminutes, and translate meeting outcomes into action plans that yield measurableresults.

Maintains reasonably regular, punctual attendance consistent with OrlandoHealth policies, the ADA, FMLA and other federal, state and local standards.

Maintains compliance with allOrlando Health policies and procedures.


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