Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

* Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

JOB SUMMARY 
The Risk Adjustment Coder III plays a critical role in advancing the organizations risk adjustment initiatives through a blend of coding expertise, provider education, project coordination, and compliance support. This position ensures accurate documentation of member diagnoses, facilitates provider engagement, and contributes to workflow improvements and strategic initiatives that enhance clinical quality and organizational performance.

JOB SPECIFICATIONS AND CORE COMPETENCIES
Coding & Documentation Accuracy
Review medical records to identify potential missed diagnoses and ensure accurate coding based on CMS, HHS, and Medicaid risk adjustment methodologies. 
Serve as second-level coder for escalated cases. 
Maintain expert knowledge of CMS and Medicaid regulations, processing guidelines, and systems. 
Analyze coding review and audit data to identify documentation trends and develop targeted education strategies. 

Provider Education & Engagement
Educate providers and stakeholders on risk adjustment concepts, proper coding, and documentation practices. 
Develop and deliver tailored educational presentations and workshops to address provider-specific needs. 
Establish and maintain positive working relationships with providers and their staff to support accurate coding. 
Track provider performance metrics related to risk adjustment and share findings with leadership.

Project Coordination & Compliance Support
Support centralized chart gathering and submission processes to ensure compliance with federal and state regulations. 
Develop and maintain tracking tools for medical record requests, invoice submissions, and project deadlines. 
Assist in the design and execution of projects that highlight service and clinical quality improvement opportunities. 
Prepare materials and support facilitation of internal and external meetings. 

Cross-Functional Collaboration & Process Improvement
Collaborate with operations, claims, analytics, and provider relations teams to align risk adjustment goals. 
Partner with internal teams to improve workflow processes, document management, and abstraction education.
Provide status updates, feedback, and recommendations based on coding review findings and project outcomes. 

Actively contributes to the achievement of departmental goals, as identified in the Departments annual business plan, including specific departmental process improvement plans, and other duties as assigned.

Reports to Position Title: Director, Risk Adjustment 

QUALIFICATIONS: 
Education/Specialized Training/Licensure: AHIMA/AAPC Certified Coder, Medical Billing and Coding certification required (CPC, CRC, COC, CCS, CCS-P) or any combination of listed certifications required.

Risk Adjustment experience in coding, auditing, provider education preferred.

Work Experience (Years and Area): Minimum of 5-7 years of experience in risk adjustment coding, provider education, and healthcare project coordination required.

2-5 years of management experience preferred

Software Proficiencies: Microsoft 365 (Word, Excel, Outlook, SharePoint, Teams)

Other: 
Strong understanding of HCC coding, CMS/HHS/Medicaid guidelines, and RADV audit processes
Excellent communication, presentation, and analytical skills 
Proficiency in EMR systems, coding software, and Microsoft Office 365
Ability to manage multiple priorities and work collaboratively across departments

Application Instructions

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