HCC Lead Coder/Auditor - Wakely

Job Summary

The HCC Lead Coder/Auditor is responsible for performing advanced coding and audit reviews of outpatient medical records to validate the integrity of ICD-10 diagnoses and CPT-coded procedures. This role applies deep knowledge of coding guidelines, risk adjustment methodologies, and regulatory requirements to ensure accuracy, compliance, and optimal reimbursement.

This position includes direct interaction with clients and requires the ability to clearly communicate audit findings, provide recommendations, and support documentation improvement efforts. In addition to core coding and auditing responsibilities, the HCC Lead Coder/Auditor analyzes trends in coding accuracy, contributes to quality improvement initiatives, and supports client engagements. This role operates with a high level of autonomy and is not solely production focused.

Specific Responsibilities

• Design and deliver targeted coding education based on audit findings, regulatory updates, and client needs.
• Develop training materials, presentations, and reference guides to support internal teams and client stakeholders.
• Translate complex coding guidelines, audit results, and regulatory requirements into clear, actionable guidance.
• Lead efforts to improve clinical documentation practices in alignment with risk adjustment requirements.
• Support client readiness for RADV and/or HRADV audits by identifying risks and providing mitigation guidance.
• Serve as a subject matter expert in ICD-10 coding and risk adjustment models (CMS-HCC and/or HHS-HCC).
• Provide expert consultation on complex coding scenarios and documentation challenges.
• Monitor regulatory and industry changes and communicate impacts to internal teams and clients.
• Influence coding and documentation practices through education, consultation, and stakeholder engagement.
• Partner with leadership to identify opportunities to enhance coding accuracy, documentation integrity, and client outcomes.
• Collaborate with internal teams and external partners to improve coding tools, workflows, and emerging technologies (e.g., LLMs).

Preferred Expertise and Knowledge

• Deep expertise in CMS-HCC and/or HHS-HCC risk adjustment models.
• Demonstrated experience developing and delivering coding education or training programs.
• Strong presentation and facilitation skills with experience engaging client stakeholders.
• Experience supporting RADV and/or HRADV audit processes and readiness efforts.

Work Performed and Job Requirements

• Coding, Auditing, and Quality Review
  • Perform complex coding and audit reviews of medical records using ICD-10-CM, ICD-10-PCS, CPT, and applicable guidelines.
  • Validate documentation accuracy and identify under- and over-coded services.
  • Apply advanced knowledge of risk adjustment models (e.g., CMS-HCC, HHS-HCC) in coding and audit processes.
  • Ensure compliance with all regulatory, payer, and internal documentation standards.
• Client Engagement & Communication
  • Communicate audit findings, coding rationale, and documentation improvement opportunities directly to clients in both written and verbal formats.
  • Participate in client meetings and presentations to discuss audit results, trends, and recommendations.
  • Build and maintain strong client relationships through professional, clear, and consultative communication.
  • Support client-specific initiatives by providing coding expertise and insights to improve documentation and coding practices. 
• Quality Improvement & Analysis
  • Analyze audit results to identify trends, patterns, and opportunities for improvement in coding practices.
  • Provide actionable recommendations to enhance documentation accuracy, coding quality, and reimbursement outcomes.
  • Support internal quality assurance processes and contribute to continuous improvement initiatives.
  • Assist in the development and refinement of audit methodologies, tools, and reporting processes.
• Operational & Team Support
  • Maintain accurate productivity, quality, and timekeeping records in accordance with department expectations.
  • Serve as a resource to team members by providing guidance on complex coding scenarios.
  • Support onboarding and informal mentorship of team members, as needed.
  • Remain current on all coding, documentation, and regulatory changes relevant to assigned work.
  • Follow HIPAA regulations and maintain compliance with all required training.
• All other duties as assigned.

Performance Emphasis

Success in this role is measured through:

• High-quality coding and audit work, demonstrated through accuracy, compliance, and adherence to regulatory and client requirements.
• Effective communication and influence of client coding and documentation practices through clear, actionable feedback.
• Demonstrated impact on documentation integrity and coding accuracy through subject matter expertise and education.
• Strong client engagement, including the ability to build trusted relationships and support client needs.
• Contribution to risk adjustment audit readiness (e.g., RADV/HRADV) through identification of risks and mitigation strategies.
• Collaboration across internal teams to support client delivery, quality improvement, and knowledge sharing.
• Initiative in identifying opportunities to enhance coding practices, documentation integrity, and overall service delivery.
  
  

Education/Training

Minimum of a high school diploma is required; an associate’s or bachelor’s degree is preferred. A current certification from AHIMA or AAPC is required (e.g., CPC, CCS-P, RHIA, RHIT, CPMA). A Certified Risk Adjustment Coder (CRC) certification is also required.

Experience

Minimum of five years of experience in medical coding and/or auditing is required. Experience working with risk adjustment models, including CMS-HCC and/or HHS-HCC, is strongly preferred. Experience supporting or participating in RADV and/or HRADV audits is preferred.

Knowledge, Skills and Abilities

• Advanced knowledge of ICD-10 coding guidelines, medical terminology, and reimbursement methodologies.
• Strong analytical skills with the ability to identify trends and provide actionable recommendations.
• Ability to interpret complex medical records and apply appropriate coding standards.
• Strong written and verbal communication skills, including the ability to present findings to clients.
• Ability to work independently and manage multiple priorities in a fast-paced environment.
• Proficiency in Microsoft Office and coding/audit systems.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

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