Senior Risk Adjustment Coding Specialist

Senior Risk Adjustment Coding Specialist

The Senior Risk Adjustment Coding Specialist serves as a subject matter expert, providing advanced coding guidance, mentoring team members, supporting audits, and contributing to process improvement initiatives.

Responsible for performing retrospective, concurrent and RADV medical record reviews to ensure accurate and compliant diagnosis coding that supports Medicare Advantage, ACA, and other risk-adjusted reimbursement programs. This role collaborates with providers, clinical staff, and operational teams to identify coding opportunities, ensure documentation integrity, and improve overall risk adjustment performance.

Essential Responsibilities:

• Perform comprehensive medical record reviews to identify, validate, and capture chronic and acute conditions according to CMS and risk adjustment guidelines.
• Assign and validate appropriate ICD-10-CM diagnosis codes based on provider documentation.
• Ensure coding accuracy and compliance with CMS-HCC, HHS-HCC, and organizational risk adjustment requirements.
• Conduct retrospective, concurrent, and prospective chart reviews.
• Identify documentation gaps and communicate findings to providers and clinical teams.
• Support provider education efforts related to risk adjustment documentation and coding best practices.
• Participate in internal and external coding audits and validation activities.
• Maintain productivity and quality standards while meeting departmental goals.
• Research and interpret coding regulations, compliance updates, and CMS guidance.
• Collaborate with quality, population health, clinical operations, and provider engagement teams.
• Track coding trends and recommend opportunities for documentation improvement.
• Maintain confidentiality and comply with HIPAA requirements.

Additional Responsibilities:

• Serve as a resource and mentor for coding specialists and clinical staff.
• Lead complex coding reviews and second-level quality audits.
• Assist with policy development, workflow optimization, and coding program initiatives.
• Analyze coding and audit results to identify trends, risks, and improvement opportunities.
• Support readiness for RADV, internal, and external audits.
• Deliver provider and staff education on coding and documentation best practices.
• Participate in cross-functional strategic projects related to risk adjustment performance.

Qualifications:

Required Qualifications:

• High school diploma or GED required; Associate's or Bachelor's degree preferred.
• Minimum 5 years of medical coding experience.
• Minimum 3 years of dedicated risk adjustment coding experience.
• Demonstrated experience supporting audits, provider education, or coding quality initiatives.
• Advanced knowledge of CMS-HCC and risk adjustment methodologies.
• Strong knowledge of ICD-10-CM coding guidelines.
• Experience reviewing electronic medical records (EMRs).
• Proficiency with Microsoft Office applications.

Required Certifications:

• Certified Professional Coder (CPC)
• Certified Risk Adjustment Coder (CRC)
• Certified Coding Specialist (CCS)
• Certified Coding Associate (CCA)

Preferred Certifications:

• CPC and CRC combination strongly preferred.
• Additional specialty coding certifications preferred.

Knowledge, Skills, and Abilities:

• Strong understanding of CMS-HCC risk adjustment methodology.
• Knowledge of Medicare Advantage and value-based care programs.
• Ability to interpret clinical documentation and coding guidelines accurately.
• Strong attention to detail and analytical skills.
• Excellent written and verbal communication skills.
• Ability to work independently and manage multiple priorities.
• Experience with coding audits and quality assurance processes.
• Proficiency with EMR systems such as Epic, Athena, eClinicalWorks, or similar platforms.
• Strong organizational and problem-solving abilities.

Preferred Experience:

• Medicare Advantage, Medicaid, ACA, or value-based care experience.
• Experience with RADV audits and risk adjustment validation programs.
• Provider education and clinical documentation improvement (CDI) experience.
• Experience working for a health plan, managed care organization, ACO, IPA, or large provider group.
• Familiarity with population health and quality improvement initiatives.