Risk Adjustment Specialist

Description

JOB SUMMARY:

The Risk Adjustment Specialist – Coding Compliance supports the organization’s delegated Risk Adjustment and Coding Compliance programs by performing specialized audit support, documentation review coordination, coding validation support, medical record analysis, and compliance activities to promote accurate and complete Hierarchical Condition Category (HCC) capture in accordance with Centers for Medicare & Medicaid Services (CMS), California Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA), Office of Inspector General (OIG), and contracted health plan requirements.

This role supports coding compliance oversight activities related to Medicare Advantage Risk Adjustment, Risk Adjustment Data Validation (RADV), provider documentation integrity, and coding accuracy initiatives. The position assists with identifying documentation gaps, monitoring coding compliance trends, coordinating audit preparation activities, and supporting provider education efforts to ensure accurate Risk Adjustment Factor (RAF) scoring and regulatory compliance.

The Risk Adjustment Specialist collaborates closely with Coding Compliance leadership, certified coders, providers, population health teams, utilization management, care management, quality improvement, and health plans to support compliant documentation and coding practices, audit readiness, and delegated risk adjustment program performance.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: High school diploma or GED equivalent required

Preferred: Associate’s degree or higher in healthcare administration, public health, social services, or related field. 

Experience 

Minimum: At least one year of experience in one or more of the following areas: risk adjustment, coding compliance, medical record review, managed care, healthcare administration, managed care or MSO environment, medical office or provider operations.

Preferred: Experience supporting Medicare Advantage Risk Adjustment programs. Experience supporting CMS RADV audits or coding compliance audits. Experience in an MSO, IPA, health plan, delegated entity, or managed care environment. Experience working with electronic health records, coding software, or Risk Adjustment platforms.

Certification(s)

Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or other coding certification preferred.

Skills, Knowledge & Abilities

• Knowledge of CMS Risk Adjustment methodology, HCC documentation requirements, and RAF score principles. 
• Understanding of Medicare Advantage Risk Adjustment, coding compliance, and documentation integrity requirements. 
• Familiarity with CMS RADV audit standards, DMHC regulatory requirements, NCQA standards, and delegated health plan oversight requirements. 
• Ability to identify documentation deficiencies, coding inconsistencies, compliance risks, and audit-related concerns. 
• Strong organizational, analytical, auditing, and data tracking skills with exceptional attention to detail and accuracy. 
• Ability to maintain accurate records, audit logs, compliance documentation, and reporting tools. 
• Proficiency with electronic health records, Risk Adjustment platforms, coding software, and Microsoft Office applications. 
• Strong verbal and written communication skills with the ability to communicate professionally with providers, coders, leadership, health plans, and interdisciplinary teams. 
• Ability to handle confidential and sensitive information in compliance with HIPAA and organizational policies. 
• Ability to manage multiple priorities, deadlines, and audit-related activities in a fast-paced managed care environment.
• Ability to work independently while collaborating effectively within interdisciplinary operational and compliance teams.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Primarily sedentary work involving prolonged computer use. Occasional standing, walking, and local travel may be required. Ability to lift up to 20 pounds occasionally. Requires strong attention to detail, data analysis capability, and effective communication skills. Work is performed in an office or remote environment supporting electronic medical record and Risk Adjustment systems.