Key Responsibilities

• Perform diagnosis code abstraction on original medical record reviews, applying ICD-10-CM coding guidelines (and ICD-9-CM for records with dates of service through September 30, 2015) in accordance with CMS-approved RADV workflows.

• Serve as the primary escalation point for Mid-Level Coders, resolving complex, ambiguous, or discrepant intake and coding issues forwarded during initial review.

• Perform appeals-related diagnosis abstraction, incorporating additional documentation and context supplied by the Medicare Advantage Organization to determine whether audited HCCs are substantiated.

• Adhere strictly to the SOW's separation-of-review requirement during appeals: coders may not review the same medical record during appeals that they reviewed during the original abstraction.

• Provide professional-quality editorial review of appeal coders' written submissions, ensuring clarity, structural consistency, and defensibility of updated coding summaries before they are sent to the RADV Appeals Support Contractor.

• Validate that documentation genuinely supports the diagnosis codes assigned, applying sound clinical and coding judgment consistent with CMS-HCC hierarchy logic.

• Consult with the Physician Consultant on complex clinical documentation questions arising during abstraction or appeals review.

• Support quality assurance sampling and inter-rater reliability (IRR) reviews as directed by the Lead Senior Coder, QA.

• Maintain a minimum 95% individual accuracy rate across all review types (intake, abstraction, and appeals).

• Contribute workflow and reporting improvement recommendations to CDAT-M based on patterns observed in escalated and appealed cases.

• Attend required CMS and RADV Independent Coding Consultant (ICC) training sessions and maintain current knowledge of evolving RADV audit methodology and coding guidance.

• Handle protected health information (PHI) and other sensitive data in strict compliance with HIPAA, CMS data confidentiality requirements, and contract-specific Data Use Agreement terms.

Requirements

Required Qualifications

• Active, valid coding certification from AHIMA or AAPC, one of the following: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Risk Adjustment Coder (CRC), Certified Coding Associate (CCA), or Certified Coding Specialist (CCS).

• Minimum of 5 years of professional coding experience, with demonstrated proficiency in both ICD-9-CM and ICD-10-CM coding guidelines.

• Demonstrated experience resolving complex or disputed coding determinations, ideally including formal escalation, quality review, or appeals-related coding work.

• Experience coding across multiple sites of service (hospital inpatient, hospital outpatient, and physician office settings).

• Strong written communication skills, with demonstrated ability to produce clear, well-organized coding rationale suitable for submission in a formal appeals or audit context.

• Ability to pass a federal background investigation and obtain the position-appropriate personnel security clearance/credential required for CMS system access (PIV or equivalent).

• Comfortable working in a fully remote, virtual-meeting environment using standard CMS-approved collaboration and secure data-exchange tools.

• Must be a U.S. citizen or otherwise authorized to work in the U.S. without sponsorship, and reside within the United States (work outside the U.S. and its territories is prohibited under this contract absent prior written government approval).

Preferred Qualifications

• Prior experience with CMS Risk Adjustment programs, RADV, HCC coding, or Medicare Advantage payment methodology.

• Prior experience specifically in a coding appeals, dispute resolution, or medical record review escalation role.

• Experience with CDAT-M or similar federal medical record review platforms.

• Bilingual Spanish/English coding capability.

Experience mentoring or providing coding guidance to less experienced coders.

Pay: $25.00 - $29.00 per hour

Application Question(s):

• Ability to pass a federal background investigation

Experience:

• ICD-9-CM and ICD-10-CM coding guidelines.: 5 years (Required)
• coding across multiple sites of service: 5 years (Required)
• CMS Risk Adjustment programs: 5 years (Required)
• RADV, HCC coding, or Medicare Advantage: 4 years (Required)
• CDAT-M or similar Federal Platforms: 5 years (Required)

Security clearance:

• Secret (Required)

Work Location: Remote