Risk Adjustment Compliance Coding Specialist, Consultant

Risk Adjustment Compliance Coding Specialist (Consultant)

The Risk Adjustment Compliance Coding Specialist (Consultant) helps to ensure organizational compliance with laws related to Risk Adjustment across our Marketplace (ACA), Medi-Cal (Medicaid), and Medicare Advantage lines of business. Specifically, the role helps to ensure the accuracy, completeness, and integrity of medical coding for risk adjustment programs. This specialist reviews clinical documentation and medical records to verify that all diagnoses and procedures are properly captured and coded in accordance with regulatory standards. By doing so, the specialist helps healthcare organizations meet compliance requirements for federal and state risk adjustment initiatives by supporting appropriate reimbursement, accurate risk stratification, and quality improvement efforts.

Responsibilities

In this role, you will:

• Comprehensive Record Review: Examine patient medical records, encounter notes, lab results, and physician documentation to identify all relevant diagnoses and health conditions that affect risk adjustment scoring.
• Accurate Code Assignment: Assign ICD-10-CM codes, including Hierarchical Condition Categories (HCC), based on thorough review of clinical evidence and in strict adherence to CMS and HHS guidelines, payer requirements, and organizational policies.
• Quality Audits: Independently conduct audits and assessments of complex issues; develop workplans, testing steps, and defensible conclusions. Perform retrospective and concurrent audits of coded data, flagging and correcting discrepancies, omissions, and upcoding or downcoding that could result in compliance issues or financial inaccuracies.
• Provider Collaboration: Engage with physicians, advanced practice providers, and clinical staff to clarify ambiguous documentation, provide education on best practices, and resolve coding questions to ensure accurate capture of patient acuity.
• Compliance Monitoring: Keep abreast of updates to federal and state regulations, coding guidelines, risk adjustment models (such as CMS-HCC, HHS-HCC), and payer-specific rules to ensure ongoing program compliance and risk mitigation. Review coding monitoring reports and identify trends, patterns of error, and systemic issues requiring corrective action. Recommend control enhancements and monitoring approaches.
• Education and Training: Develop and deliver training sessions and educational materials to coding staff, providers, and ancillary teams on risk adjustment principles, compliant documentation, and the significance of accurate coding for organizational success.
• Reporting and Analysis: Generate detailed reports summarizing audit results, coding trends, compliance risks, and quality improvement opportunities, presenting findings to leadership and compliance committees. Translate findings into clear actions.
• Audit Support: Assist with internal and external audits by preparing requested documentation, supporting audit responses, and implementing corrective action plans to address identified deficiencies.
• Prioritize work based on risk and regulatory deadlines; recommend resource needs.
• Perform other duties as assigned.

Qualifications

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience. A degree in Health Information Management, Nursing, Health Administration, or a related clinical field is preferred
• Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential is required.
• Requires a minimum of 7 years of experience in compliance audit, risk adjustment coding, medical coding, compliance auditing, or similar roles in a healthcare setting. Experience with Medicare Advantage, ACA plans, or Medicaid Managed Care is highly preferred
• Requires deep familiarity with compliance risk assessments and audits
• Requires direct experience supporting or responding to CMS RADV audits, internal coding compliance audits, or OIG related reviews is strongly preferred.
• Requires advanced proficiency in ICD-10-CM coding, electronic health record (EHR) systems, coding audit tools, and Microsoft Office Suite (Word, Excel, PowerPoint, Outlook). Experience with risk adjustment analytics software is a plus
• Requires an in-depth understanding of risk adjustment models (CMS-HCC, HHS-HCC), Official Coding Guidelines, payer policies, and regulatory requirements (CMS, HHS, OIG, DHCS)
• Requires exceptional analytical and critical thinking abilities, meticulous attention to detail, strong organizational and time management skills, and the capacity to interpret and summarize complex clinical documentation
• Requires ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and to deliver a quality work product in a highly regulated, demanding, and constantly changing corporate environment
• Requires outstanding written and verbal communication skills

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.