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Risk Adjustment Consultant

Expired Job

Tufts Medical Center Boston , MA 02298

Posted 5 months ago

  • Associate's degree required

  • Under the direction of the Executive Director of Population Health, performs accurate and timely review and validation of Medicare, Medicaid, and Commercial HCCs through medical record reviews. The Risk Adjustment Consultants review provider documentation of ICD-9-CM/ICD-10-CM codes to verify that coding meets both established coding standards as well as CMS Risk Adjustment guidelines.

    The Risk Adjustment Consultant will lead efforts to evaluate the HCC coding practices and provide analyses and recommendations to improve overall provider documentation and coding. The Risk Adjustment Consultant will review medical records to determine if diagnostic codes (ICD-9-CM/ICD-10-CM) are accurately reflecting the provider documentation. The coder will summarize findings for internal and external parties.

    Performs ongoing audit of medical records for BPC and network providers to ensure diagnosis coding accuracy. Performs medical record audit to determine coding accuracy to coding standards and CMS regulations. Evaluates medical records for appropriate written and electronic signatures as well as other technical requirements.

    Summarizes and interprets audit findings for TMCPO/NEQCA Leadership; tracks audit results over time, identifies trends, and recommends corrective actions. Collaborates with TMCPO/NEQCA staff and vendors to identify and submit coding adjustments, as needed. Maintains a current and strong understanding of coding rules and CMS guidelines in both inpatient and outpatient settings.

    Interprets and summarizes coding guidelines and CMS regulations for TMCPO/NEQCA leadership. Incorporates changes to guidelines and regulations into audit practice. Researches and resolves coding and risk adjustment regulatory issues.

    Coding Program Evaluation. Provides coding expertise to evaluate internal coding program opportunities. Provide BPC and network providers trainings and updates as needed.

    Summarizes and presents recommendations to key internal staff. Reporting. Review and work audit lists provided by Executive Director, Population Health, and create reports from coding initiatives as defined. Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action.


Associates degree or equivalent.

Minimum 5 years inpatient or outpatient billing and coding experience, CRC credentials required.

Excellent organizational and interpersonal skills are essential as well as the ability to work on multiple tasks, to work under pressure, meet deadlines and provide excellent follow up.

Communication skills are essential.

The ability to give oral presentations to staff as well as written skills to prepare reports for management.

The ability to work effectively as a member of a team is essential.

Work in an office setting.

Frequent contact with physicians and their office staff, insurance representative, medical directors, department heads and administrative managers.

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Risk Adjustment Consultant

Expired Job

Tufts Medical Center