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Compliance Specialist - HCC


Implement and maintain Coding Compliance programs in accordance with the Office of Inspector General's work plan, to reduce institutional and individual provider legal and financial risk through internal audits, training and education.

Additionally increase revenue, accuracy of payment and quality of care by identifying, training/educating and submitting unreported valid medical diagnosis and delegating diagnosis that were submitted inappropriately.


  • Educate providers in regarding compliance with government regulations with special attention to Center for Medicare and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and Fraud and Abuse with periodic updates.
  • Assist in performing analysis of current situations and recommend priorities and goals for future clinic needs. Identify coding and billings risk areas, conduct focused reviews, and implement corrective action as needed.
  • Conduct routine internal audits of provider documentation on a timely basis. Collaborate with physicians and internal staff in development of improved capabilities in the areas of documentation, coding, and compliance.
  • Review internal controls, policies, and procedures to ensure compliance with appropriate University, State, and Federal guidelines and policies, sound business and finance practices, and overall clinical goals and objectives.
  • Respond promptly to external and internal concerns; implementing corrective actions as appropriate.
  • Communicate with Medicare/Medicaid Carriers and third party payers regarding policies and procedures.
  • Promote Compliance initiatives with clinical faculty and administration.
  • Ability to review documentation and abstract all codes with specific emphasis on identifying the most accurate severity of illness according to CMS HCC guidelines
  • Leverage Healthcare Effectiveness Data and Information Set (HEDIS) to measure provider performance on important aspects of care and service
  • Collaborate with CDI Representative to provide timely feedback that will assist with validating and reporting appropriate measures of accuracy
  • Offers recommendations and develops templates and tips for capturing the HCC’s at the patient encounter
  • Serve as HCC subject matter expert in conjunction with CDIS program lead(s) to providers, practice managers.
  • Coordinate activities related to Coding Quality Assurance/Audit. Be actively engaged in coding, abstracting and medical data research to include review and analysis of data input, processing and data output activities. 
  • Develop and present educational training programs to hospital and medical coding staff, and staying educational collaborations such as Bulletin Review from Payers and review of coding queries.
  • Conducts both random and focused reviews timely for accurate documentation and coding to coding operations.  
  • Identifies coding and billing risk areas and communicates timely through the appropriate channels/forums those areas that require escalation.
  • Collaborates with internal staff in development of improved capabilities in coding and compliance.
  • Responds promptly to external and internal concerns with regard to correct coding policies.  Identifies errors on claims and sends to the Claim Correction Department for processing.
  • Assists with education of providers in regard to compliance and government regulations with special attention to CMS and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and Fraud and Abuse with periodic updates.
  • Maintains knowledge regarding policies and procedures with Medicare/Medicaid Carriers and third party payers; including HCC and RAF guidelines
  • Collaborates with Internal Compliance Department to promote excellence in correct documentation and coding.
  • Interacts effectively and professionally with colleagues to provide helpful information in response to inquiries, concerns and requests.
  • Develops and maintains strong working relationships with both internal and external customers.
  • Perform other related duties incidental to the work described herein. 


  • Work requires organization, analytical and communication skills generally acquired through the completion of a Bachelor's degree program -OR- equivalent experience of 5+ years in coding, auditing, and developing and presenting educational material.
  • 4+ years of administrative experience is required to acquire competency in applying compliance, coding and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle related functions. 
    • For technical coding, 2 of the 4 years of experience with DRG's and APR-DRG's is required. Experience in formal teaching of coding is preferred. RHIA or RHIT or CCS required. 
    • For professional coding, specialty coding experience in E/M coding preferred.CPC or CCS or RHIT or RHIA or CPMA is required. Secure HCC related certifications in a year’s time.
  • Knowledge, Skills, and Abilities:
    • Medicare Risk Adjustment/HCC Coding 
    • Proficient in Excel, PPT and WORD
    • Excellent Written and Verbal Communication Skills
    • Ability to work across a matrix environment
    • Presentation Instructional/Training Skills
    • Good Problem Solving and Critical Thinking Skills


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