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 Work

In this role, you will:

• Comprehensive Record Review: Examine patient medical records, encounter notes, lab results, and physician documentation to identify all relevant diagnoses and health conditions that affect risk adjustment scoring.
• Accurate Code Assignment: Assign ICD-10-CM codes, including Hierarchical Condition Categories (HCC), based on thorough review of clinical evidence and in strict adherence to CMS and HHS guidelines, payer requirements, and organizational policies.
• Quality Audits: Independently conduct audits and assessments of complex issues; develop workplans, testing steps, and defensible conclusions. Perform retrospective and concurrent audits of coded data, flagging and correcting discrepancies, omissions, and upcoding or downcoding that could result in compliance issues or financial inaccuracies.
• Provider Collaboration: Engage with physicians, advanced practice providers, and clinical staff to clarify ambiguous documentation, provide education on best practices, and resolve coding questions to ensure accurate capture of patient acuity.
• Compliance Monitoring: Keep abreast of updates to federal and state regulations, coding guidelines, risk adjustment models (such as CMS-HCC, HHS-HCC), and payer-specific rules to ensure ongoing program compliance and risk mitigation. Review coding monitoring reports and identify trends, patterns of error, and systemic issues requiring corrective action. Recommend control enhancements and monitoring approaches.
• Education and Training: Develop and deliver training sessions and educational materials to coding staff, providers, and ancillary teams on risk adjustment principles, compliant documentation, and the significance of accurate coding for organizational success.
• Reporting and Analysis: Generate detailed reports summarizing audit results, coding trends, compliance risks, and quality improvement opportunities, presenting findings to leadership and compliance committees. Translate findings into clear actions.
• Audit Support: Assist with internal and external audits by preparing requested documentation, supporting audit responses, and implementing corrective action plans to address identified deficiencies.
• Prioritize work based on risk and regulatory deadlines; recommend resource needs.
• Perform other duties as assigned.

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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