Risk Adjustment Compliance Coding Specialist, Consultant

Your Role

The Risk Adjustment Compliance Coding Specialist (Consultant) helps to ensure organizational compliance with laws related to Risk Adjustment across our Marketplace (ACA), Medi-Cal (Medicaid), and Medicare Advantage lines of business. Specifically, the role helps to ensure the accuracy, completeness, and integrity of medical coding for risk adjustment programs. This specialist reviews clinical documentation and medical records to verify that all diagnoses and procedures are properly captured and coded in accordance with regulatory standards. By doing so, the specialist helps healthcare organizations meet compliance requirements for federal and state risk adjustment initiatives by supporting appropriate reimbursement, accurate risk stratification, and quality improvement efforts.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience. A degree in Health Information Management, Nursing, Health Administration, or a related clinical field is preferred
• Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential is required.
• Requires a minimum of 7 years of experience in compliance audit, risk adjustment coding, medical coding, compliance auditing, or similar roles in a healthcare setting. Experience with Medicare Advantage, ACA plans, or Medicaid Managed Care is highly preferred
• Requires deep familiarity with compliance risk assessments and audits
• Requires direct experience supporting or responding to CMS RADV audits, internal coding compliance audits, or OIG related reviews is strongly preferred.
• Requires advanced proficiency in ICD-10-CM coding, electronic health record (EHR) systems, coding audit tools, and Microsoft Office Suite (Word, Excel, PowerPoint, Outlook). Experience with risk adjustment analytics software is a plus
• Requires an in-depth understanding of risk adjustment models (CMS-HCC, HHS-HCC), Official Coding Guidelines, payer policies, and regulatory requirements (CMS, HHS, OIG, DHCS)
• Requires exceptional analytical and critical thinking abilities, meticulous attention to detail, strong organizational and time management skills, and the capacity to interpret and summarize complex clinical documentation
• Requires ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and to deliver a quality work product in a highly regulated, demanding, and constantly changing corporate environment
• Requires outstanding written and verbal communication skills

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