Risk Adjustment Coding Specialist II

Location: 600 City Parkway West 10th Floor, Orange, CA 92868

About the Role

We are seeking a highly motivated Risk Adjustment Coding Specialist to enable us to continue scaling in the healthcare industry. This role will report to a Sr. Manager - Risk Adjustment and requires frequent travel to provider sites depending on projects.

Responsibilities

• Review provider documentation of diagnostic data from medical records to verify that all Medicare Advantage, Affordable Care Act (ACO), and Commercial risk adjustment documentation requirements are met.
• Deliver education to providers on either an individual basis or in a group forum, as appropriate for all IPAs managed by the company.
• Review medical record information on both a retroactive and prospective basis to identify, assess, monitor, and document claims and encounter coding information as it pertains to Hierarchical Condition Categories (HCC).
• Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation to ensure adherence with CMS Risk Adjustment guidelines.
• Interact with physicians regarding coding, billing, documentation policies, procedures, and conflicting/ambiguous or non-specific documentation.
• Meet or exceed productivity targets as established by management and regularly meet assigned due dates.
• Prepare and/or perform auditing analysis and provide feedback on noncompliance issues detected through auditing.
• Maintain current knowledge of coding regulations, compliance guidelines, and updates to the ICD-10 and HCC codes. Stay informed about changes in Medicare, Medicaid, and private payer requirements.
• Keep management apprised of project activities through regular written and oral status reports. Proactively identify risks that may hinder project success.
• Provide recommendations to management related to process improvements, root-cause analysis, and/or barrier resolution applicable to Risk Adjustment initiatives.
• Train, mentor, and support new employees during the orientation process. Function as a resource to existing staff for projects and daily work.
• Provide peer-to-peer guidance through informal discussion and overread assignments. Support coder training and orientation as requested by manager.
• May assist or lead projects and/or handle a higher work volume than Risk Adjustment Coding Specialist I.

Requirements

• Must possess and maintain AAPC or AHIMA certification – Certified Coding Specialist (CCS) and/or Certified Professional Coder (CPC). Certified Risk Adjustment Coder (CRC) is a plus but not required.
• Minimum of 3-5 years’ experience in risk adjustment coding and/or billing experience.
• Reliable transportation, valid Driver’s License, and ability to travel at least 75% of work time.
• Proficiency with PC skills and experience using Microsoft applications such as Word, Excel, and PowerPoint.
• Excellent presentation, verbal, and written communication skills, with the ability to collaborate effectively.
• Ability to educate and train provider office staff members.
• Proficiency with healthcare coding software and Electronic Health Records (EHR) systems.

Skills

• Knowledge of Risk Adjustment and Hierarchical Condition Categories (HCC) for Medicare Advantage.
• Ability to work independently and collaborate in a team setting.
• Strong organizational and time-management skills.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Provider Clinic service region for meetings and/or training as needed.
• Able to work independently and within time constraints.
• Able to efficiently prioritize multiple high-priority tasks.

Pay

The national target pay range for this role is $70,000 - $85,000 per year. Actual compensation will be determined based on geographic location, experience, and other job-related factors.

Schedule

This position blends on-site fieldwork (approximately 75% travel) with remote support to help practices. The work arrangement may be modified, including transitioning to a hybrid or onsite model, based on business needs.