Risk Adjustment Compliance Coding Specialist, Consultant

Helps ensure organizational compliance with laws related to Risk Adjustment across Marketplace (ACA), Medi-Cal (Medicaid), and Medicare Advantage lines of business. The role ensures the accuracy, completeness, and integrity of medical coding for risk adjustment programs by reviewing clinical documentation and medical records to verify proper capture and coding of diagnoses and procedures in accordance with regulatory standards.

Responsibilities

• Examine patient medical records, encounter notes, lab results, and physician documentation to identify all relevant diagnoses and health conditions that affect risk adjustment scoring.
• 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.
• 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.
• 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.
• 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.
• 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.
• Generate detailed reports summarizing audit results, coding trends, compliance risks, and quality improvement opportunities, presenting findings to leadership and compliance committees.
• 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.

Requirements

• 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.
• Minimum of 6 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.
• Deep familiarity with compliance risk assessments and audits.
• Direct experience supporting or responding to CMS RADV audits, internal coding compliance audits, or OIG related reviews is strongly preferred.
• 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.
• In-depth understanding of risk adjustment models (CMS-HCC, HHS-HCC), Official Coding Guidelines, payer policies, and regulatory requirements (CMS, HHS, OIG, DHCS).
• 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.
• Ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and deliver a quality work product in a highly regulated, demanding, and constantly changing corporate environment.
• Outstanding written and verbal communication skills.

Schedule

This role requires employees to be in-office based on a 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.

Pay

Pay range for California: $123,090.00 to $184,800.00. Pay range for Bay Area: $138,756.00 to $208,320.00. Note: This range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Salaries are based on candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

About Us

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.

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.

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.