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Job Summary

The Risk Adjustment Coder III is responsible for the accurate and timely assignment of medical diagnosis codes in accordance with established risk adjustment models, coding guidelines, and organizational standards. This role performs high-volume, production-based coding and chart review activities, following defined policies and procedures to ensure compliance and data accuracy. This position applies advanced coding knowledge but operates within established guidelines, with work subject to quality review and audit.

Duties & Responsibilities

Essential Duties & Responsibilities

• Medical Coding and Documentation
• Assign ICD-10-CM diagnosis codes based on medical records, clinical documentation, and encounter data in accordance with established coding guidelines.
• Perform detailed chart reviews to ensure accurate capture of diagnoses, including HCC codes, following risk adjustment requirements.
• Identify and correct coding discrepancies based on documented evidence and coding standards.
• Maintain required productivity and quality benchmarks for coding volume and accuracy.
• Risk Adjustment Compliance
• Apply CMS-HCC and other risk adjustment coding guidelines in daily work activities.
• Follow established compliance protocols to ensure coding meets regulatory and internal standards.
• Participate in routine coding audits and apply feedback to improve accuracy and consistency.
• Data Quality & Accuracy
• Ensure all assigned codes are supported by appropriate clinical documentation.
• Track and report coding errors or inconsistencies to leadership.
• Maintain accuracy standards as defined by departmental performance metrics.
• Collaboration and Support
• Work collaboratively with coding team members, clinical documentation staff, and leadership to resolve coding issues.
• Provide guidance and support to junior coders as directed by leadership.
• Participate in team meetings, training sessions, and workflow discussions.
• Education and Development
• Maintain current knowledge of ICD-10-CM coding updates and risk adjustment guidelines.
• Complete required training and continuing education to maintain certifications.
• Apply updates and changes to coding practices as directed.

Supervisory Responsibilities

• Work is performed under general supervision with clearly defined procedures and guidelines.
• Exercises judgment within established coding standards; does not set policy or interpret regulations independently.
• Work is regularly reviewed for accuracy, quality, and productivity.

Education & Experience

• High school diploma or equivalent.
• Associate's degree or certification in Health Information Management, Medical Coding, or related field is preferred.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required.
• Certified Risk Adjustment Coder (CRC) preferred.
• 5 years of experience in medical coding with a focus on risk adjustment or HCC coding.
• Extensive knowledge of ICD-10-CM coding guidelines and risk adjustment methodologies.
• Experience with medical record review, documentation guidelines, and auditing.

Education Requirements

Required/Preferred

Education Level

Discipline

Required

High School Diploma

Required

Certification

Certified Professional Coder (CPC)

Required

Certification

Certified Coding Specialist (CCS)

Preferred

Certification

Certified Risk Adjustment Coder (CRC)

Knowledge, Skills & Proficiencies

• Five (5) years prior medical coding experience (ICD-10, CPT, and HCPCS).
• Expertise of Medicare Risk Adjustment methodology.
• Additional AAPC specialty certifications (CPMA, CDEO, etc.).
• Excellent knowledge of ICD-10-CM coding conventions and guidelines.
• Excellent communication skills, both written and verbal, for engaging with clinical teams, physicians, and management.
• Strong analytical skills with attention to detail.
• Ability to review and interpret medical records and clinical documentation effectively.
• Ability to work independently and prioritize tasks in a fast-paced environment.
• Demonstrated critical thinking and decision-making skills relative to clinical documentation.
• Experience with medical record review and documentation auditing.

Physical Requirements

This position works under usual office conditions. The associate is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing.

Travel Requirements

Amount of Expected Travel

Details

Required

0-25%

Flexibility to travel to clinical sites as needed

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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