Under the direction of the Manager of Clinical Documentation Improvement, the Data Integrity Specialist is responsible for reviewing and ensuring the accuracy, completeness, and compliance of risk adjustment coding for all internal claim submissions. This role plays a critical function in supporting organizational performance under value-based care contracts by conducting pre-claim, concurrent, and retrospective audits, identifying coding and documentation gaps, and driving continuous improvement in performance. The ideal candidate brings deep expertise in ICD-10-CM and CMS-HCC, HHS, and Medicaid risk adjustment methodologies and collaborates closely with Clinical Documentation Improvement (CDI) Specialists.

RESPONSIBILITIES

• Ensure compliance with all applicable CMS Risk Adjustment Methodology rules and regulations related to coding and documentation guidelines for Risk Adjustment.
• Maintain a consistent review of daily production volume per day while adhering to a 95%–98% accuracy threshold.
  Demonstrate the ability to process cases per hour for standardized risk adjustment encounters.
• Perform pre-claim audits and issue corrections to improper codes documented on encounters prior to submission to ensure claim accuracy, completeness, and compliance with ICD-10-CM and all Medicaid, Medicare and ACA HCC model guidelines.
• Validate that all reported diagnoses are fully supported by clinical documentation and meet MEAT (Monitor, Evaluate, Assess Plan) criteria to ensure compliance. Ensure documentation shows a chronic condition is actively managed during a face-to-face visit.
• Identify and remediate unsupported, suspect, or inaccurately coded conditions before claim submission to mitigate compliance and financial risk
• Complete retrospective audits to identify trends, missed opportunities, and areas for improvement in coding and documentation
• Participate in concurrent and prospective reviews, helping to identify documentation and coding Monitor performance through accuracy trends, audit results, and turnaround times
• Partner closely with CDI teams to align audit findings with provider education and documentation improvement strategies
• Maintain adherence to internal compliance policies and external regulatory requirements
• Support audit readiness for internal, external, and health plan audits (e.g., RADV, plan audits)
• Analyze trends in audit results to inform CDI Manager on risk areas and improvement strategies
• Participate in special projects related to risk adjustment strategy, including prospective programs and suspecting initiatives

QUALIFICATIONS

• Must have a minimum of 4 years experience in ICD-10 Auditing
• Current coding certification to include one of the following: CRC, CPC, CPC-H (no CPC-As for this role) required.
• High school diploma required; Bachelors Degree in Healthcare, Finance or Business preferred.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes and pharmacology.
• Advanced knowledge of ICD-9-CM, ICD-10-CM, CPT and HCPCS coding, medical terminology and regulatory requirements are required.
• Proficient in the Microsoft Office Suite, Coding and compliance standards.
• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling and proper word usage, grammar, punctuation, and sentence structure.
• Keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment required.
• Orientation toward analytical problem solving with practical, results-oriented mindset.
• Ability to manage multiple priorities while maintaining a positive attitude.
• Demonstrated integrity, discretion, and maturity.

Base Salary/ Wage Range $65,000 - $75,000 plus annual bonus. Compensation for the role is commensurate with the candidate’s qualifications, skills, competencies, and experience and may fall outside of the range shown. ConcertoCare offers a competitive total rewards package, which includes full healthcare coverage, a 401K with match, and a broad range of other health, wellness, and financial benefits.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

ConcertoCare is an Alcohol/Drug/Smoke-Free Workplace