Under the direction of the Manager of Clinical Documentation Improvement, the Coding Quality Improvement Specialist is a coding-focused role responsible for auditing risk adjustment coding across internal workflows to ensure accuracy, completeness, and compliance. This individual will lead pre-claim, concurrent, and retrospective audit activities, validating that diagnoses are fully supported and aligned with ICD-10-CM and Centers for Medicare & Medicaid Services (CMS) risk adjustment guidelines. In addition to core audit responsibilities, this role supports Clinical Documentation Improvement (CDI) efforts by translating audit findings into actionable, provider-focused education on the importance of diagnosis specificity, developing, presenting, and disseminating provider communications and other activities related to clinical documentation.

RESPONSIBILITIES

• Ensure compliance with all applicable CMS Risk Adjustment Methodology rules and regulations related to coding and documentation guidelines for Risk Adjustment
• Responsible for supporting the development and implementation of a comprehensive Clinical Documentation Improvement (CDI) risk adjustment and provider outreach program to support all ConcertoCare provider groups & payor partnerships.
• Serve as a liaison between ConcertoCare and Risk Adjustment vendors for efforts related to the Medical Record Review process: provider alert compliance activity; and provider education on proper coding and documentation.
• Oversee assigned providers and markets while being responsible for provider education/engagement monthly. Identifying areas for improvement and routinely monitoring success of the clinical documentation provider engagement model. Perform chart review and analysis of provider activity around HCC conditions documented at date of service, query generation for documentation requiring improvement
• Review for clinical indicators and query providers to capture the severity of illness of the patient.
• Assists in the development tools for provider education on documentation accuracy.
• Communicate effectively with team, leadership, and internal departments as necessary to address issues and concerns.
• 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 of a provider supporting role and 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.
• Strong written communication skills (professional correspondence, grammar, and attention to detail).
• Efficient keyboarding and comfort using software to produce reports, charts, and spreadsheets.
• Orientation toward analytical problem solving with practical, results-oriented mindset.
• Ability to manage multiple priorities while maintaining a positive attitude.
• High integrity, professionalism, and maturity.

Base Salary/ Wage Range $75,000 - $80,000 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