Job Description

Job Title: Certified Coding Specialist I-HealthPlan (Risk Adjustment)
Job ID: 722435
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: MEDICARE HCC
Location: 600 Grant St, Pittsburgh PA 15219


Are you looking to take the next step in your coding career?  The UPMC HealthPlan is searching for a Certified Coding Specialist I to join their Risk Adjustment team.  This role needs to have the ability to code using ICD-10-CM and appropriately assign diagnosis and procedure codes after reviewing all documentation available.  The Coding Specialist performs audits to determine accuracy of code selection and assists with risk adjustment validation (RADV) audits.  This position is responsible for validating diagnoses submitted via claims to the Health Plan by reviewing inpatient, outpatient and provider office documentation. The role also assists with inter-rater reliability audits and conducts review of coded materials to ensure compliance with coding guidelines and principles and CMS Risk Adjustment Participant Guidelines.  The position identifies topics for training and education and assists with training of new hires.

This role is work from home after training/orientation is complete.  Sound like a fit for you?  Apply today!

  • Abstract required medical and demographic information from the medical record and enter the data into the system to ensure accuracy of the database.
  • Also coordinate re-training of staff as needed due to coding changes/updates, results of audits, etc. Communicate effectively with Patient Business Services, physicians and ancillary departments as necessary to submit accurate and timely billing.
  • Assign the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology and pathology.
  • Assist with identifying continuing education needs and opportunities.
  • Assist with training new staff for inpatient, SDS and ED coding.
  • Code Inpatient, SDS and ED charts as necessary.
  • Complete work assignments in a timely manner.
  • Coordinate continuing education by contacting clinical staff and arranging in-services for the coding staff, as well as keeping current with other education being offered by AHIMA and other professional organizations.
  • Determine diagnoses that were treated, monitored and evaluated and procedures done during the episode of care and assign appropriate codes.
  • Develop and present Inpatient/SDS/ED coding seminars for continuing coder education as coding issues are identified from the auditing process.
  • Discuss audit findings with each coder individually as needed for further clarification.
  • Ensure the diagnoses and procedures are sequenced in order of their clinical significance to accurately assign the appropriate DRG, APC or payment tier under the Prospective Payment system to guarantee accurate reimbursement on UPMC patients.
  • Identify areas of coding weakness and develop training plans to address these.
  • Identify incomplete documentation in the medical record and formulate a physician query to obtain missing documentation and/ or clarification to accurately complete the coding process.
  • Perform internal quality assurance audits on inpatient, SDS, and ED coded records.
  • Perform reviews on Third Party Audit findings/outcomes and prepare report for HIM and Compliance.
  • Provide audit findings to coding staff members electronically for coders to review.
  • Responsible for correcting any data found to be in error after reviewing the medical record and comparing with system entries.
  • Review and evaluate focused UPMC DRG or APC medical records for accurate payment prior to billing to ensure that all documented principal and secondary diagnoses, complications and co-morbidities, and procedures are accurately coded.
  • Review coding for accuracy and completeness prior to submission to billing.
  • Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.
  • Submit a monthly auditing/training schedule to the Manager.
  • Submit all educational documents for all patient types to Management.
  • Submit audit summaries for Inpatient, SDS and ED coding.
  • Submit completed Inpatient, SDS, and ED audit spreadsheets with details for each chart.
  • Summarizes findings and report these to the Manager.
  • Utilize computer applications and resources essential to completing the coding process efficiently, such as QuadraMed encoder, Cerner and MARS to ensure timely billing.
  • Utilize standard coding guidelines and principles and coding clinics to assign the appropriate ICD-10-CM and CPT codes including modifiers for correct DRG/APC assignment and accurate reimbursement.


  • Graduate of an AHIMA or AAPC Certified Coding Program that includes Anatomy & Physiology, Pharmacology and Medical Terminology. 
  • Associates Degree from an accredited Health Information Management program preferred. 
  • Five years of total experience.

Licensure, Certifications, and Clearances:
  • Certified Coding Specialist or Certified Professional Coder or Registered Health Information Administrator or Registered Health Information Technician

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $22.60 to $39.11 / hour

Union Position: No

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