The Risk Adjustment Coder Specialist ensures accurate medical diagnosis data submission to CMS for CenCal Health’s Medicare Advantage D-SNP line of business. This role supports diagnosis documentation accuracy, identifies barriers to appropriate risk adjustment, oversees outsourced vendor coding for CMS compliance, and partners with provider outreach teams to educate providers on accurate and comprehensive medical coding.
Key responsibilities include:
- Review medical records to identify, validate, and ensure accurate capture of diagnosis codes aligned with CMS-HCC, HHS-HCC, ICD-10-CM, and applicable risk adjustment requirements.
- Oversee vendor coding activities by monitoring work quality, reviewing coded records, validating findings, resolving discrepancies, and providing feedback.
- Collaborate with provider groups and internal departments to resolve coding questions, clarify documentation, improve chart review processes, and promote compliant risk adjustment practices.
- Develop and deliver education for providers and clinical staff on CMS risk adjustment guidelines, compliant documentation practices, diagnosis specificity, and accurate coding standards.
- Identify documentation gaps, coding trends, and improvement opportunities, and partner with clinical, quality, analytics, compliance, and provider-facing teams to strengthen risk adjustment outcomes.
- Support internal, external, and CMS Risk Adjustment Data Validation audits by preparing documentation, reviewing audit samples, validating diagnosis support, and assisting with responses.
- Maintain and update coding guidance, workflows, reference materials, and job aids to reflect CMS risk model updates, ICD-10-CM changes, and process improvements.
- Analyze coding and documentation data to identify patterns, measure program effectiveness, track vendor performance, and support leadership reporting.
- Serve as a coding resource and subject matter expert on risk adjustment diagnosis coding, documentation requirements, and CMS regulatory updates.
Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or a closely related field.
Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or equivalent certification.
Three or more years of risk adjustment coding experience in Medicare Advantage, Affordable Care Act, or Medicaid.
Three or more years of experience in a health plan or managed care setting.
Additional qualifications and skills:
- Expert knowledge of CMS-HCC or HHS-HCC risk adjustment models, including diagnosis-to-HCC mapping, hierarchy logic, and annual model updates.
- Strong knowledge of ICD-10-CM Official Guidelines for Coding and Reporting, medical terminology, and risk adjustment coding standards.
- Ability to identify unsupported, unspecified, inaccurate, deleted, or duplicate diagnosis codes and recommend corrections.
- Demonstrated skill in identifying documentation gaps, missed chronic conditions, coding trends, and provider education opportunities.
- Excellent written, verbal, interpersonal, and presentation skills.
- Proficiency in Microsoft Word, PowerPoint, Outlook, and intermediate Excel skills.
- Ability to monitor outsourced coding vendor performance, review quality results, communicate audit findings, and escalate concerns when needed.
- Understanding of CMS Medicare regulatory expectations, RADV audit concepts, overpayment risk, compliance controls, and documentation standards.
- Strong analytical and problem-solving skills.
- Ability to maintain confidentiality, protect member health information, and work in compliance with HIPAA and organizational policies.
Location
California, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
3 weeks ago