Risk Adjustment and HCC Coding Leader for AI Evaluation

Lead risk-adjustment and HCC coding efforts to evaluate and improve AI tools used to enhance risk score accuracy and coding completeness across Medicare Advantage, Medicaid managed care, and ACA markets. You will apply deep HCC methodology and RADV audit experience to review AI-generated coding, guide documentation improvements, and produce structured annotations that inform AI training and validation.

• Lead risk adjustment and HCC coding operations across Medicare Advantage, Medicaid, and/or ACA risk adjustment programs.
• Evaluate AI-generated HCC coding assignments and risk adjustment recommendations for clinical accuracy and regulatory compliance.
• Review medical records to ensure complete and accurate capture of HCC-eligible conditions supported by clinical documentation.
• Conduct and oversee retrospective and prospective chart reviews aimed at risk score optimization.
• Manage RADV audit preparation and response processes.
• Monitor risk adjustment KPIs, including HCC capture rates, risk score accuracy, and chart retrieval rates.
• Collaborate with clinical, coding, and compliance teams to improve documentation and coding for risk adjustment purposes.
• Ensure compliance with CMS risk adjustment guidelines, including RAPS and EDGE submission processes, and Official Coding Guidelines.
• Annotate AI outputs and provide structured coding feedback to support AI training datasets.

• Minimum 5 years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, including at least 2 years in a leadership role.
• Deep expertise in CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies.
• Strong knowledge of ICD-10-CM coding guidelines as applied to HCC risk adjustment.
• Experience with RADV audit preparation and CMS compliance requirements.
• Familiarity with RAPS and EDGE submission processes.
• Exceptional written and verbal English communication skills.
• High attention to detail, with the ability to identify coding inaccuracies and documentation gaps in AI-generated outputs.

• CRC (Certified Risk Coder), CCS, CPC, or RHIA credential.
• Experience with risk adjustment analytics platforms and chart retrieval systems.
• Background in a health plan, Medicare Advantage organization, or value-based care setting.
• Familiarity with AI-assisted HCC coding tools and comfort evaluating AI-generated risk adjustment content.
• Experience presenting risk adjustment performance to actuarial or executive teams.

• Location: Remote.
• Engagement type: Hourly.

• Pay rate: $110.00 per hour.

• Must be able to review medical records and related clinical documentation to confirm complete and accurate capture of HCC-eligible conditions supported by the documentation.