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Medicare Risk Adjustment Chart Review Jobs in California

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Medicare Risk Adjustment Chart Review information

What is Medicare Risk Adjustment Chart Review?

Medicare Risk Adjustment Chart Review is a process where healthcare professionals review patient medical records to identify and validate diagnoses that impact Medicare Advantage risk scores. This ensures that Medicare Advantage plans receive accurate reimbursement based on the health status and complexity of their enrollees. The review helps to capture any conditions that may not have been coded during patient visits, improving data accuracy and compliance with CMS regulations.

What are some common challenges faced in a Medicare Risk Adjustment Chart Review role, and how can they be managed?

A common challenge in Medicare Risk Adjustment Chart Review is ensuring the accuracy and completeness of medical documentation to support proper coding and risk adjustment. Reviewers often encounter incomplete records or ambiguous provider notes, which requires strong attention to detail and effective communication with healthcare staff to clarify information. Staying current with CMS guidelines and coding updates is essential, as regulations and requirements can change frequently. Proactively collaborating with providers and participating in regular training sessions can help manage these challenges and improve review quality.

What are the key skills and qualifications needed to thrive as a Medicare Risk Adjustment Chart Reviewer, and why are they important?

To thrive as a Medicare Risk Adjustment Chart Reviewer, you need a solid understanding of medical coding (CPT, ICD-10), healthcare compliance, and clinical documentation, often supported by a coding certification such as CPC, CRC, or CCS. Familiarity with electronic medical records (EMRs), risk adjustment software, and auditing tools is typically required. Attention to detail, analytical thinking, and strong communication skills set top performers apart in accurately interpreting and reporting clinical data. These competencies are crucial for ensuring accurate risk adjustment, regulatory compliance, and optimized reimbursement for healthcare organizations.

What is the difference between Medicare Risk Adjustment Chart Review vs Medical Coder?

AspectMedicare Risk Adjustment Chart ReviewMedical Coder
Primary FocusReviewing patient charts to ensure accurate risk adjustment data for MedicareAssigning medical codes based on clinical documentation for billing and records
CertificationsOften requires coding certifications and knowledge of Medicare guidelinesCertified Professional Coder (CPC) or equivalent
Work EnvironmentHealthcare facilities, insurance companies, or remoteHospitals, clinics, or billing companies
Industry UsageMedicare Advantage plans, risk adjustment programsMedical billing, coding, and documentation

While both roles involve medical documentation, Medicare Risk Adjustment Chart Review focuses on analyzing charts to optimize Medicare risk scores, whereas Medical Coders assign codes for billing purposes. Understanding these differences helps in choosing the right career path or job focus within healthcare documentation and billing.

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Cities in California with the most Medicare Risk Adjustment Chart Review job openings:

Medicare Risk Adjustment Chart Review jobs near you

Sr Risk Adjustment Coder

University HealthCare Alliance

Fremont, CA • On-site

$25 - $33/hr

Other

This job post has expired today. Applications are no longer accepted.

Job description

Senior Risk Adjustment Coder

The Senior Risk Adjustment Coder will perform code audits and abstraction in accordance with all state regulations, federal regulations, internal policies, and internal procedures. The HCC Coding Auditor Senior will be involved with activities of quality assurance auditing and risk adjustment code abstraction for the following programs: including but not limited to Medicare Advantage Risk Adjustment.

What you will do:

  • Risk Adjustment Review
  • May perform prospective and concurrent Clinical Documentation Improvement (CDI) workflows as well as retrospective auditing
  • Reviewing medical records to ensure accurate HCC coding and identify opportunities for recapture and suspect diagnoses.
  • Evaluating medical records to verify that M.E.A.T criteria support the submitted diagnosis codes.
  • Inquire with clinicians the recommended HCC diagnosis for chart addendum.
  • Collaborating with other departments to address coding updates and support risk adjustment programs.
  • Compliance Reporting
  • Tracking and reporting review results that will be used to develop education and training materials on risk adjustment coding and/or documentation best practices.
  • Assist with the implementation of emerging coding and compliance laws and regulations and assist with implementing privacy policies.
  • Maintain current knowledge of risk adjustment coding guidelines by conducting research, reading professional publications, and maintaining professional networks. Attending coding seminar, webinars and medical organization meetings.
  • All other duties as assigned including department-specific functions and responsibilities:
  • Performs other duties as assigned and participates in organization projects as assigned.
  • Adheres to safety, P4P's (if applicable), HIPAA and compliance policies.

Education Qualifications:

  • High school diploma or GED equivalent.
  • Bachelor's Degree preferred.

Experience Qualifications:

  • 5+ years of work experience in a risk adjustment program supporting and communicating with clinicians with prospective and/or concurrent role within a healthcare setting with demonstrated knowledge and of regulatory billing and coding guidelines.
  • Understanding of the professional revenue cycle preferred.

Required Knowledge, Skills and Abilities:

  • Knowledge of CPT, HCPCS and ICD-10 codes and rules.
  • Ability to analyze and develop solutions to complex problems.
  • Ability to perform research regarding complex coding and regulatory guidelines.
  • Ability to work effectively both as a team player and leader.
  • Ability to apply judgment and make informed decisions.
  • Ability to foster effective working relationships and build consensus.
  • Ability to make effective oral presentations and prepare concise written reports to a variety of audiences.
  • Ability to plan, organize, prioritize, work independently and meet deadlines.
  • Knowledge of computer systems and software used in functional area.
  • Knowledge of local, state and federal regulatory requirements related to areas of functional responsibility.
  • Demonstrated knowledge of CPT, HCPCS and ICD-10 codes and rules.
  • Ability to establish and maintain collaborative effective working relationships.
  • Ability to bring together multi-disciplinary teams to seek consensus and value problem.

Licenses and Certifications:

  • CPC - Certified Professional Coder and
  • CRC - Certified Risk Adjustment Coder
  • CCDS - Cert Clinical Document Spec preferred

Physical Demands and Work Conditions Physical Demands:

  • Constant Sitting.
  • Frequent Walking.
  • Occasional Standing.
  • Occasional Bending.
  • Occasional Squatting.
  • Occasional Climbing.
  • Occasional Kneeling.
  • Seldom Crawling.
  • Constant Hand Use.
  • Constant Repetitive Motion Hand Use.
  • Frequent Grasping.
  • Occasional Fine Manipulation.
  • Frequent Pushing and Pulling.
  • Occasional Reaching (above shoulder level).
  • Frequent Twisting and Turning (Neck and Waist).
  • Constant Vision (Color, Peripheral, Distance, Focus).

Lifting:

  • Frequent lifting of 0 - 10 lbs.
  • Occasional lifting of 11 - 20 lbs.
  • Seldom lifting of 21 - 30 lbs.
  • Seldom lifting of 31 - 40 lbs.
  • Seldom lifting of 40+ lbs.

Carrying:

  • Frequent lifting of 0 - 10 lbs.
  • Occasional lifting of 11 - 20 lbs.
  • Seldom lifting of 21 - 30 lbs.
  • Seldom lifting of 31 - 40 lbs.
  • Seldom lifting of 40+ lbs.

Working Environment:

  • Occasional Driving cars, trucks, forklifts and other equipment. May be required to drive personal vehicle to sites.
  • Constant Working around equipment and machinery. Office equipment (computers, phones, fax, copy machines, printers, 10-key, etc.).
  • Seldom Walking on uneven ground.
  • Seldom Exposure to excessive noise.
  • Seldom Exposure to extremes in temperature, humidity or wetness.
  • Seldom Exposure to dust, gas, fumes or chemicals.
  • Seldom Working at heights.
  • Seldom Operation of foot controls or repetitive foot movement.
  • Seldom Use of special visual or auditory protective equipment.
  • Seldom Use of respirator.
  • Seldom Working with biohazards such as blood borne pathogens, hospital waste, etc..
  • Seldom Other (please list each item under Comments):.

Blood Borne Pathogens:

  • Category III - Tasks that involve NO exposure to blood, body fluids or tissues, and Category I tasks that are not a condition of employment

Travel Requirements:

  • 10% travel:

These principles apply to ALL employees: SHC Commitment to Providing an Exceptional Patient & Family Experience Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do this by executing against our three experience pillars, from the patient and family's perspective:

  • Know Me: Anticipate my needs and status to deliver effective care
  • Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
  • Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $44.13 - $57.36 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

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