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Optum Certified Risk Adjustment Coder in Colorado Springs, Colorado

Job Description

Job Title: Senior Medical Coder

FLSA: Non-Exempt

Department: Clinical Performance

Reports to: Manager of Coding and Auditing

Segment/Business: Coding/Clinical Performance

Location: Remote

New/Updated: 08/19/2020

Eff Date: 08/19/2020

Schedule: Full Time Monday - Friday

This position has the opportunity to be remote

Job Summary

Evaluates clinical coding from medical records to ensure accurate coding of encounter data and recommends processes to ensure accurate and efficient coding practices. Assists in providing feedback regarding coding and reimbursement. Participate in operational activities. Work with network managers, medical director, market leader, stakeholders and other employees to ensure improvement in coding accuracy. Position maintains high level (96%) coding accuracy and completes work within assigned queue in established timeframe. Performs coding querying, adds missed codes. Identifies deletes, code validation, identifies suspects

Major Responsibilities

  • Leverage understanding of disease process to identify and extract relevant details and data within clinical documentation and make determination or identify appropriate ICD-10 &/or CPT codes following CMS guidelines

  • Evaluates documentation to ensure that diagnosis coding is complete, supported, and meets specificity requirement to support clinical indicators, HEDIS and STARS quality measures, as required by client.

  • Identifies suspect/unreported HCC codes in the notes/records to reflect the severity of the patient's condition.

  • Performs level one concurrent or retrospective coding quality reviews.

  • Queries providers regarding missing, unclear, or conflicting health record documentation through the use of approved templates consistent with Optum Coding Guidelines.

  • Resolve medical coding edits or billing item rejects in relation to code assignment.

  • Work with assigned providers, network managers, medical director, market leader, stakeholders and/or other employees to ensure improvement in provider coding accuracy, as necessary.

  • Performs the minimum number of coding quality reviews consistent with established departmental goals.

  • Maintains a 96% quality audit accuracy rate.


  • High school diploma or GED equivalent.

  • Coding Certification from AAPC or AHIMA professional coding association (CPC, RHIT, RHIA, CCS, CRC).

  • 3+ years’ experience in ICD-10-CM or 2 years minimum experience in HCC Coding required.

  • Knowledge of CMS Risk Adjustment and HCC Coding process.

  • Strong attention to detail.

  • Ability to perform in a deadline driven environment.

  • Ability to maintain professionalism and a positive service attitude at all times.

  • Working knowledge of CPT/Evaluation and Management guidelines.

  • Requires strong verbal/written communication and interpersonal skills.

  • Ability to analyze facts and exercise sound judgment when arriving at conclusions.

  • Ability to effectively report deficiencies with a recommended solution in oral and/or written form.

  • Microsoft Office proficiency (Word, Excel, PowerPoint & Outlook) preferred.