• This role will have all responsibilities of coding assistant, coder I and II plus the following: assist with special projects as requested, assists with training other coders as requested, Monitors and responds to accounts in the charge router, charge router messages, CRMs, Compliance and Integrity review requests. • Adhere to organizational and internal department policies and procedures to ensure efficient work processes. • Reviews complex medical documentation at a highly skilled and proficient level from clinicians, qualified health professionals and hospitals in order to assign diagnosis and procedure codes utilizing ICD-10 CM/PCS, CPT, and HCPCS. • Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations utilizing an EMR and/or Computer Assisted Coding software. • Serves as subject matter expert in your assigned specialty and actively participate in the Coding meetings as a problem solver. • Follow up and obtain clarification of inaccurate documentation as appropriate. • Maintain continuing education by attending webinars, reviewing updated CPT assistant guidelines and updated coding clinics. • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. • Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement. • Maintains the confidentiality of patient records. • Reports any perceived non-compliant practices to the coding leader or compliance officer. • Meets and exceeds departmental quality (95% or more) and productivity standards (100%). • Achieves productivity expectations to support discharged not final billed (DNFB).

• Review participant medical records and provider documentation to identify, validate, and code risk-adjustable diagnoses in accordance with CMS-HCC v24 and v28 guidelines. • Ensure complete, accurate, and compliant ICD-10-CM coding with a primary focus on concurrent and retrospective reviews (with flexibility for pre-visit planning as needed). • Draft and submit compliant provider queries to clarify documentation and support accurate coding. • Track and follow through on open queries—engaging with providers, monitoring responses, and closing them out appropriately. • Apply strong critical thinking skills to resolve complex documentation and coding scenarios. • Maintain clear, professional communication with providers and internal teams to support documentation completeness. • Stay current with CMS, OIG, and industry regulations related to risk adjustment and coding compliance.

• Generate comprehensive and concise in-depth reporting and analysis for Pre-Pay and Post-Paid Processes • Provide Provider Pre Pay production and progress reports and coordinate with management and team • Recommend process or procedure changes and build strong relationships with cross departmental teams • Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts • Identify knowledge gaps and provide training opportunities • Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws • Responsible for making claim payments decisions on a variety of claims • Respond to claim questions and concerns and prepare claims for Medical Director review

• Abstract and assign valid CPT, ICD-10, HCPCs and modifiers • Identify compliance concerns • Educate on proper coding and documentation