Risk Adjustment Specialist

LSMA Management Inc•San Bernardino, CA

8h•Hybrid

About The Position

The Risk Adjustment Specialist – Coding Compliance supports the organization’s delegated Risk Adjustment and Coding Compliance programs by performing specialized audit support, documentation review coordination, coding validation support, medical record analysis, and compliance activities to promote accurate and complete Hierarchical Condition Category (HCC) capture in accordance with Centers for Medicare & Medicaid Services (CMS), California Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA), Office of Inspector General (OIG), and contracted health plan requirements. This role supports coding compliance oversight activities related to Medicare Advantage Risk Adjustment, Risk Adjustment Data Validation (RADV), provider documentation integrity, and coding accuracy initiatives. The position assists with identifying documentation gaps, monitoring coding compliance trends, coordinating audit preparation activities, and supporting provider education efforts to ensure accurate Risk Adjustment Factor (RAF) scoring and regulatory compliance. The Risk Adjustment Specialist collaborates closely with Coding Compliance leadership, certified coders, providers, population health teams, utilization management, care management, quality improvement, and health plans to support compliant documentation and coding practices, audit readiness, and delegated risk adjustment program performance.

Requirements

High school diploma or GED equivalent required
At least one year of experience in one or more of the following areas: risk adjustment, coding compliance, medical record review, managed care, healthcare administration, managed care or MSO environment, medical office or provider operations.
Knowledge of CMS Risk Adjustment methodology, HCC documentation requirements, and RAF score principles.
Understanding of Medicare Advantage Risk Adjustment, coding compliance, and documentation integrity requirements.
Familiarity with CMS RADV audit standards, DMHC regulatory requirements, NCQA standards, and delegated health plan oversight requirements.
Ability to identify documentation deficiencies, coding inconsistencies, compliance risks, and audit-related concerns.
Strong organizational, analytical, auditing, and data tracking skills with exceptional attention to detail and accuracy.
Ability to maintain accurate records, audit logs, compliance documentation, and reporting tools.
Proficiency with electronic health records, Risk Adjustment platforms, coding software, and Microsoft Office applications.
Strong verbal and written communication skills with the ability to communicate professionally with providers, coders, leadership, health plans, and interdisciplinary teams.
Ability to handle confidential and sensitive information in compliance with HIPAA and organizational policies.
Ability to manage multiple priorities, deadlines, and audit-related activities in a fast-paced managed care environment.
Ability to work independently while collaborating effectively within interdisciplinary operational and compliance teams.

Nice To Haves

Associate’s degree or higher in healthcare administration, public health, social services, or related field.
Experience supporting Medicare Advantage Risk Adjustment programs.
Experience supporting CMS RADV audits or coding compliance audits.
Experience in an MSO, IPA, health plan, delegated entity, or managed care environment.
Experience working with electronic health records, coding software, or Risk Adjustment platforms.
Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or other coding certification preferred.

Responsibilities

Perform specialized audit support
Documentation review coordination
Coding validation support
Medical record analysis
Compliance activities to promote accurate and complete HCC capture
Support coding compliance oversight activities related to Medicare Advantage Risk Adjustment, RADV, provider documentation integrity, and coding accuracy initiatives
Identify documentation gaps
Monitor coding compliance trends
Coordinate audit preparation activities
Support provider education efforts
Collaborate closely with Coding Compliance leadership, certified coders, providers, population health teams, utilization management, care management, quality improvement, and health plans