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HCC Coding Specialist

Highmark Inc.

  • Company Highmark
  • Home, PA
  • Claims
  • Full time
  • Day (United States of America)

Company :

Highmark Inc.

Job Description : 


* Work From Home Opportunity for Healthcare Coder

This job is responsible for the successful delivery of detailed and complex medical record reviews for Regulatory Audits. The incumbent is responsible to interface with appropriate departments (i.e., Gov't Compliance, RPM Coding, RPM Analytics, RPM Audit Strategy/Project Manager, RPM Programs chart retrieval, and Spectrum Development).  The incumbent is responsible for completion of final pass Quality Assurance review of medical records and coding for appropriate interpretation and designations including chart documentation ranking, chart HCC coding selection, Attestations for provider signature requirements, and creating detail oriented, appropriate package for submission to government agency.  Ensure compliance with required Regulatory Audit guidelines are being met with regards to coding, cover sheets and attestations prior to Regulatory Audit Package submission. The incumbent will be required to participate in all Gov't Regulatory Audit training calls, and monitor / review all Regulatory Audit publications from Government Agencies, BCBSA, and AHIP;  prepare detailed description of questions for needed interpretation and review by Gov't Compliance for submission to Gov't Agency.  The incumbent takes a lead role in supporting  implementation of process improvements related to provider documentation and coding to improve performance in Regulatory Audits and claims data submission.  Conduct analytics per audit to identify opportunities for improvement in performance and interface with Analytics to create evidence based provider education based on results of audits, and communicate needed updates to RPM policies based on audit findings, including but not limited to RPM Coding Guidelines, CDV, and RCDV policies. 


  • Lead regulatory audits for coding teams.  Ensure completion of projects to meet regulatory / departmental deadlines.  Provide business and/or subject matter expertise for regulatory audits.  Responsible to communicate and collaborate with management to assemble, and mentor, audit coding team(s) to ensure deliverables are met, or exceeded.
  • Responsible for all Quality Assurance reviews by coding team, to ensure compliance with CMS Coding Guidelines and Highmark Coding Guidelines.  Review and analyze weekly reports to ensure appropriate quality review performance and results.  Take lead role in providing updates to RPM CDV and RCDV policies based on provider documentation and coding trends identified. 
  • Analyze audit reporting for prioritization of work for cross-functional departmental teams, based on coding results for identification of program's medical record rechases, provider op's or other internal team provider/medical record escalations, provider attestation retrievals, and chart chase cancellations throughout the project life-cycle.
  • Prepare final audit packages per exact specifications for upload to Regulatory Auditor. To include, complete, accurate and detailed cover sheet;sequence medical records appropriately, and attach completed Attestation if required.  Prepare detailed post-audit reports regarding analysis of non-validated HCCs and Attestation retrieval. Assist Compliance and Legal Dept with Appeals of Regulatory Audit final determinations .   Interface with Compliance and Legal Dept regarding Appeals of Regulatory Audit final determinations.   
  • Conduct data analyses from medical record reviews to identify opportunities to improve provider documentation and coding for members in regards to assignment of ICD10-CM codes to chronic conditions.Interface with the revenue programs provider education teams to identify educational opportunities for targeted providers. Identify and collaborate in developing process improvement initiatives.
  • Participate in all Regulatory Audit training, monitor publications from regulatory agencies, AHIMA, BCBSA and other authoritative sources (i.e. Wakely for audit changes, corrections and clarifications) to make updates to current processes ensure  audit coding compliance.
  • Other duties as assigned or requested.



  • Associate's Degree in Healthcare, Clinical or Business Related


  • 3 years experience with RADV and/or Quality Assurance of HCC coding and documentation in lieu of Associate degree




  • 7 years with RADVs and/or Coding Regulatory Audits

To Include:

  • 5 years with HCC coding and documentation, including quality assurance reviews


  • 5 years of Coding Project Management

To Include:

  • 3 years of monitoring, evaluating audit progress, reporting and work prioritization within cross functional teams



  • Certified Coding Specialist (CCS)
  • Certified Professional Coder (CPC) OR  Certified Registered Coder (CRC) OR  Registered health Information Administrator (RHIA)


  • None


  • Understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
  • Understanding of statistics is also preferred in order to analyze various reports and validate study methodologies
  • Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles
  • Demonstrated computer literacy and knowledge of information systems and comparative data bases.  Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.
  • Analytical and problem solving skills with the ability to understand and interpret clinical data

Language (Other than English):


Travel Requirement:

0% - 25%


Position Type


Teaches / trains others regularly


Travel regularly from the office to various work sites or from site-to-site


Works primarily out-of-the office selling products/services (sales employees)


Physical work site required


Lifting: up to 10 pounds


Lifting: 10 to 25 pounds


Lifting: 25 to 50 pounds


Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Referral Level Payout 2

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity ( )

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