CareFirst BlueCross BlueShield

CareFirst BlueCross BlueShield seeks an experienced Risk Adjustment Coding Specialist to support retrospective risk adjustment, RADV audits, and related coding functions. The role involves reviewing medical records, ensuring compliance with coding guidelines, and developing Commercial Risk Adjustment coding guidelines. The position requires 3 years of HCC coding experience, RHIT/RHIA preferred, and CCS/CCS-P or CRC upon hire. #J-18808-Ljbffr

Position Overview The Senior Medical Coding Specialist acts as an internal expert to ensure that value‑based reimbursement and medical policy models are developed and implemented to support Payment Integrity. This role provides expert knowledge to support effective partnership with provider entities, guidance on the appropriate quality‑measure capture and proper use of CPT and ICD‑10 codes in claims submissions. The specialist utilizes coding expertise, combined with medical policy, credentialing and contracting rules knowledge, to build effective guidelines and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. This role also provides expertise and mentoring to other team members and will sit within the Payment Integrity team. Essential Functions Consult on proper coding rules in value‑based contracts to ensure appropriate quality‑measure capture and proper use of...