Risk Adjustment Senior Coding and Outreach Specialist

Blue Cross and Blue Shield of Kansas•Topeka, KS

4d•$31 - $39•Hybrid

About The Position

The Risk Adjustment Senior Coding and Outreach Specialist is responsible for performing advanced, complex, and audit sensitive risk adjustment coding and quality activities in support of Affordable Care Act (ACA), Medicare Advantage (MA), and Risk Adjustment (RA) Programs. This role serves as a subject matter expert in CMS risk adjustment methodologies, ICD-10-CM coding, and documentation requirements, operating with a high degree of autonomy and professional judgement to ensure coding accuracy, compliance, and audit readiness. The Senior Coder identifies, assesses, and mitigates coding and documentation risk, partners closely with leadership, and makes independent decisions that directly impact RAF accuracy, audit outcomes and regulatory compliance. “This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.”

Requirements

High school diploma or equivalent required
Active professional coding credential CRC required
Minimum of 4 years of experience in Coding or Risk Adjustment required
Advanced knowledge of ICD-10-CM coding, HCC models, and CMS risk adjustment regulations required
Proven experience managing and prioritizing high-volume workloads required
Proficiency with electronic health records (EHRs) and risk adjustment coding tools required

Nice To Haves

Experience conducting quality audits and providing feedback or education preferred
2+ years' Experience in Risk Adjustment Coding preferred
1+ year of leadership experience preferred
Familiarity with CMS audits (RADV), internal audits, or compliance reviews preferred

Responsibilities

Act as an SME in retrospective CMS Commercial and MA risk adjustment coding, including HCC mapping, ICD-10-CM guidelines, and documentation standards.
Lead and support daily retrospective coding operations, monitoring productivity, quality, and data integrity while prioritizing work based on regulatory risk and audit exposure.
Ensure accurate validation of diagnosis codes submitted through EDPS and EDGE processes, exercising professional judgment in complex or non?standard scenarios.
Conduct quality assurance reviews of internal and vendor coding, providing feedback to improve coding accuracy and consistency and reduce downstream audit risk.
Educate and mentor junior coders and CDI staff, including review of work product, feedback on accuracy, and guidance on complex coding scenarios, without formal supervisory responsibility.
Research and resolve complex coding scenarios using official ICD-10-CM guidelines, CMS guidance, and approved coding resources defending coding decisions as needed in audit or leadership review contexts.
Track, analyze, and document audit results to identify trends, risks, and opportunities for process improvement and coder education.
Identify and support initiatives to enhance claims coding accuracy, documentation quality, and risk score integrity.
Collaborate with chart retrieval teams, data analytics, project managers, and leadership to support retrospective Risk Adjustment project goals and timelines.
Ensure compliance with HIPAA, CMS audit protocols, and all applicable regulatory and organizational requirements.
Promote a culture of compliance, integrity, and audit defensibility, ensuring all coding activities meet regulatory and organizational standards.
Participate in provider education initiatives by identifying documentation gaps and contributing to targeted feedback, training materials, or coding tip sheets.