Senior Analyst, Risk Adjustment Strategy

Job Description

Job Description

Description

About the Role
We are currently seeking a highly motivated Risk Adjustment Strategy Senior Analyst. This role will report to the Chief Quality Officer and enable us to continue to scale in the healthcare industry.

This position authors and refines the coding policy and documentation standards that govern risk adjustment. You will define how conditions are captured, how documentation must support them, how ambiguous cases are resolved, and how our coding positions are defended in audit. It is a rule-defining role rather than a production coding role. Our internal coders, clinical documentation reviewers, and provider education teams work from the standards you draft and maintain.

Our Values

• Put Patients First

• Empower Entrepreneurial Provider and Care Teams

• Operate with Integrity & Excellence

• Be Innovative

• Work As One Team

What You'll Do

• Author, refine, and govern the risk adjustment coding and documentation standards. The working copy of the single source of truth that internal coders, CDI reviewers, and provider education follow across all IPAs managed by the company
• Translate risk adjustment model specifications and payer requirements into clear, enforceable coding rules, and keep those rules current as models and guidance change
• Define encounter and source-of-truth rules i.e. which encounter types, provider types, settings, and data sources support a risk-adjustable diagnosis and which do not, documenting the regulatory basis for each
• Set MEAT/TAMPER documentation criteria by condition category, compliant query rules, and an adjudication path with a versioned decision log, so ambiguous cases are resolved the same way by every coder in every market
• Establish program guardrails that produce accurate capture not upcoding. This includes chart review scope rules and deletion obligations when review surfaces unsupported codes
• Own audit defense, chart standards written backwards from the audit, sampling and validation logic, and written position papers defending coding positions when they are challenge
• Own regulatory change control across ICD-10-CM Official Guidelines, AHA Coding Clinic, and applicable payer and regulatory updates, and drive training and formal attestation for every coder and CDI reviewer on the standard in effect
• Build the coder quality rubric and inter-rater reliability standard used to measure our internal coding team
• Build the SQL reporting that sizes opportunity and measures policy impact, coder accuracy, and inter-rater reliability; partner with Compliance, CDI, Data Science, Actuarial/Finance, and Provider Network
• Keep management apprised of project activities through regular written and oral status reports, and proactively identify compliance and revenue risks that may hinder program success

Qualifications

• Required Certification/Licensure: Must possess and maintain AAPC Certified Risk Adjustment Coder (CRC) certification. CPC, CCS, RHIA, CDIP, or CCDS is a plus but not required
• 7+ years of experience in risk adjustment, including direct ownership of coding policy, clinical documentation integrity standards, or audit defense, not solely production coding
• Demonstrated experience authoring standards that others were required to follow, such as a coding policy manual, coding rules, documentation guidelines, quality rubrics, or audit protocols
• Working command of risk adjustment model mechanics, including the ability to reason about an unfamiliar model from its published specification
• Expert ICD-10-CM knowledge, fluent in the Official Guidelines and AHA Coding Clinic, with the judgment to recognize when a payment model’s rules are narrower than the code set’s
• Advanced SQL and Excel; comfort working with claims, encounter, supplemental, and pharmacy data
• Excellent written and verbal communication crafting documents that survive Compliance and Legal review while remaining usable by a coder
• Proficiency with healthcare coding software and Electronic Health Records (EHR) systems
• Ability to travel occasionally to our Orange, CA headquarters and, as needed, to other Astrana locations where our coding teams are based (up to 20% of work time)

You're a great fit for the role if:

• You have owned/authored coding policy 
• You have both payer-side and provider/MSO-side risk adjustment experience
• You have exposure to encounter data pipelines or managed care plan reporting
• You understand how program design creates or avoids False Claims Act exposure in risk adjustment
• You are comfortable declining a revenue-positive idea that the documentation or the model does not support, and can explain the reasoning
• You default to citation where every standard traces to a regulation, official guideline, model specification, or contract term
• You write for the reader who must apply the rule, and you would rather define a standard than inherit one
• You are organized, can prioritize competing high-priority work, and can work in a home office for continuous periods of time for business continuity

Environmental Job Requirements and Working Conditions

• This position is remotely based in the U.S. The home office is located at 1668 S. Garfield Ave. 2nd Floor, Alhambra, CA 91801.
• This role is required to attend occasional in-person meetings with internal departments and external providers/hospitals, training, or audit purposes. 
• The national target pay range for this role is between $90,000 - $120,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.