Coding & Risk Adjustment Specialist – Clinical Operations

Avail Health•Danville, CA

14h•Remote

About The Position

Avail Health is a rapidly growing value-based care company delivering comprehensive, technology-enabled care programs to Medicare patients with complex medical, behavioral health, and social needs. Our care model spans a range of clinical programs including Comprehensive Diagnostic Assessments (CDAs), Health Risk Assessments (HRAs), and Integrated Care Programs (ICPs), all designed to address the whole-person needs of high-risk Medicare beneficiaries. As Avail Health continues to scale its clinical programs, we are seeking an experienced Risk Adjustment & Coding Expert to serve as a trusted fractional advisor to our clinical and operational leadership team. This role sits at the intersection of clinical documentation, Medicare coding compliance, and program-level performance—supporting our mission to deliver high-quality, accurately documented care that reflects the true complexity of our patient population. The Risk Adjustment & Coding Expert will advise clinical leaders on proper HCC (Hierarchical Condition Category) coding practices, ensure documentation integrity across Avail's care programs, and drive ongoing workflow design, policy development, and process improvement to support accurate and compliant risk adjustment coding. This individual will function as a subject-matter expert embedded within Avail's interdisciplinary team structure, working collaboratively with Nurse Practitioners, Physicians, RN Care Managers, and operational leadership. This is a startup-style healthcare environment where subject-matter experts are expected to be hands-on, pragmatic, and solutions-oriented. The ideal candidate brings deep Medicare Advantage risk adjustment expertise, strong knowledge of CMS coding guidelines, and a track record of building scalable coding education and quality programs within complex care or value-based care organizations.

Requirements

Certified Risk Adjustment Coder (CRC); Certified Professional Coder (CPC) also highly desirable
Minimum 5 years of experience in Medicare risk adjustment coding, HCC coding, or clinical documentation improvement (CDI) required.
Deep knowledge of ICD-10-CM coding guidelines, CMS HCC models (V24, V28), and Medicare Advantage risk adjustment methodology.
Prior experience advising clinical providers (NPs, MDs, RN Care Managers) on coding and documentation practices.
Experience designing or delivering coding education and training programs for clinical teams.
Proficiency with EMR platforms, coding tools, and documentation review workflows.
Ability to work independently in a fractional/part-time capacity with strong self-direction and accountability.

Nice To Haves

Experience working in value-based care, Medicare Advantage, population health, or complex care management environments strongly preferred.
Familiarity with CDAs, HRAs, Annual Wellness Visits (AWVs), and Transitional Care Management (TCM) coding preferred.
Experience with RADV audits, coding compliance programs, and risk adjustment quality initiatives preferred.

Responsibilities

Performs audits on existing coding staff
Serve as the primary coding and risk adjustment subject-matter expert for Avail Health clinical leaders and frontline clinicians across CDAs, HRAs, and ICPs.
Advise Nurse Practitioners, Physicians, and RN Care Managers on accurate ICD-10-CM coding, HCC capture, and documentation requirements to support proper Medicare risk adjustment.
Review clinical encounter documentation and provide real-time feedback on coding accuracy, specificity, and completeness.
Identify coding gaps, missed HCC capture opportunities, and documentation deficiencies across care programs and patient populations.
Provide guidance on condition-specific coding requirements for high-prevalence chronic conditions within Avail's patient population (e.g., diabetes, CHF, COPD, CKD, behavioral health diagnoses).
Partner with clinical and operational leadership to design and implement coding workflows integrated into Avail's care program delivery model.
Develop and maintain coding and documentation policies, guidelines, and standard operating procedures (SOPs) aligned with CMS requirements and Medicare Advantage risk adjustment best practices.
Support the development of documentation templates, encounter coding checklists, and structured data capture tools within the EMR and care coordination platforms.
Define escalation pathways and quality review workflows for coding discrepancies, queries, and corrections.
Design and deliver ongoing coding education and training programs for Avail's clinical team, including onboarding content for new clinicians and refresher training for existing staff.
Develop program-specific coding guides, quick-reference tools, and clinical documentation resources for CDAs, HRAs, and ICPs.
Partner with the VP of Care Delivery and Medical Director to integrate coding best practices into clinical workflows, quality reviews, and care team huddles.
Support providers in navigating complex coding scenarios including dual diagnoses, behavioral health coding, and social determinants of health (SDOH) documentation.
Conduct coding audits and documentation reviews across a sample of clinical encounters to assess coding accuracy, completeness, and compliance with CMS and Medicare Advantage plan requirements.
Track and report on coding quality metrics, HCC capture rates, and risk adjustment performance trends to clinical and operational leadership.
Identify opportunities for process improvement related to risk adjustment documentation and coding workflows, and lead structured improvement initiatives.
Stay current on CMS HCC model updates, Medicare Advantage coding guidelines, and regulatory changes affecting risk adjustment; proactively communicate relevant changes to the team.
Support preparation for coding audits, RADV (Risk Adjustment Data Validation) reviews, and compliance activities as needed.
Provide targeted coding and documentation guidance specific to the clinical workflows and patient populations within each of Avail's core care programs.
Support alignment between CDA, HRA, and ICP documentation requirements and risk adjustment coding capture to ensure program integrity and compliance.
Collaborate with care program managers and clinical leads to embed coding best practices into program design, clinician onboarding, and ongoing quality oversight.