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Role Description

The Coding Compliance Specialist is responsible for overseeing and evaluating assigned Risk Adjustment Data Validation (RADV) medical record review (MRR) work performed under the contract. This role ensures compliance with CMS RADV guidelines, coding standards, and risk adjustment policies while maintaining the highest quality and accuracy in medical record documentation. This is a part-time, remote position with flexible scheduling, ideal for experienced professionals seeking autonomy and work-life balance.

Key Responsibilities

• Ensure adherence to CMS RADV payment and risk adjustment policies.
• Provide expert guidance on coding and documentation standards, including ICD-CM, HCC, and Risk Adjustment.
• Review escalated Medicare RADV medical record cases and resolve complex issues.
• Maintain quality assurance and compliance across all RADV review activities.
• Collaborate with stakeholders to improve processes and ensure contractual obligations are met.
• Conduct medical record, coding, and policy research.
• Develop and deliver training programs related to RADV and coding compliance.
• Perform medical record reviews involving PHI/PII, identify conflicting documentation, and provide coding clarifications.

Qualifications

• Prior experience working directly on the CMS RADV contract is required.
• Minimum 5 years of supervisory experience in medical record review, preferably RADV.
• Proven expertise in reviewing escalated Medicare RADV medical record cases.
• In-depth knowledge of RADV Medical Record Review (MRR) processes, ICD-CM coding standards, CMS RADV payment and risk adjustment policies, and documentation guidelines.

Education & Certification

• Medical Coding Certification from an accredited entity (e.g., AAPC, AHIMA).
• RHIT, RHIA, CCS, CPC, CRC.
• Advanced knowledge of coding systems and compliance regulations.

Skills & Competencies

• Strong analytical and problem-solving skills.
• Excellent communication and leadership abilities.
• Detail-oriented with a commitment to accuracy and compliance.
• Ability to manage multiple priorities and meet deadlines.