Risk Adjustment Compliance Coding Specialist, Consultant

Blue Shield of California • Oakland, CA

1d • Hybrid

About The Position

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.

Requirements

• 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 regard 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.

Responsibilities

• Ensure organizational compliance with laws related to Risk Adjustment across Marketplace (ACA), Medi-Cal (Medicaid), and Medicare Advantage lines of business.
• Ensure the accuracy, completeness, and integrity of medical coding for risk adjustment programs.
• Review clinical documentation and medical records to verify that all diagnoses and procedures are properly captured and coded in accordance with regulatory standards.
• Support appropriate reimbursement, accurate risk stratification, and quality improvement efforts.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed