Senior Risk Adjustment Specialist

The Senior Risk Adjustment Factor (RAF) Specialist supports Vivant’s risk adjustment initiatives within the Medicare Advantage line of business. This advanced role ensures accurate and complete documentation and coding of diagnoses to optimize member RAF scores, supporting quality patient care and accurate reimbursement under CMS guidelines. Collaborates closely with providers, coders, and care management teams to identify and implement opportunities for RAF improvement through education, chart reviews, and data analysis.

Responsibilities include coding and membership report reconciliation, leading provider education and audit programs, reviewing clinical documentation for CMS-HCC compliance, monitoring RAF score trends, conducting chart reviews, partnering with provider offices to ensure accurate encounter data submission, collaborating with coding teams to reconcile risk scores, supporting provider education on documentation and coding practices, compiling RAF performance dashboards, supporting audits related to Medicare risk adjustment, participating in outreach for annual wellness visits, staying current with CMS updates and regulations, and developing workflow improvements.

Requirements:

• 5-8 years experience in Risk Adjustment, HCC coding, or Medicare Advantage operations
• Preferred 3-5 years in IPA or health plan environment
• Knowledge of ICD-10, HCC models, CMS guidelines, Medicare Advantage programs
• Proficiency in EMR/EHR, risk adjustment analytics, Microsoft Office
• Excellent communication, analytic, and organizational skills
• Certification such as CPC, CRC, CPMA or equivalent required
• High School Diploma or GED required; Associate's or Bachelor's preferred
• Valid California Driver’s license and reliable transportation

Work Environment: Professional office setting, use of computers, office equipment; travel up to 25% required.