Senior Risk Adjustment Coding Specialist
About The Position
The Senior Risk Adjustment Coding Specialist serves as a subject matter expert, providing advanced coding guidance, mentoring team members, supporting audits, and contributing to process improvement initiatives. Responsible for performing retrospective, concurrent and RADV medical record reviews to ensure accurate and compliant diagnosis coding that supports Medicare Advantage, ACA, and other risk-adjusted reimbursement programs. This role collaborates with providers, clinical staff, and operational teams to identify coding opportunities, ensure documentation integrity, and improve overall risk adjustment performance.
Requirements
- High school diploma or GED required
- Minimum 5 years of medical coding experience
- Minimum 3 years of dedicated risk adjustment coding experience
- Demonstrated experience supporting audits, provider education, or coding quality initiatives
- Advanced knowledge of CMS-HCC and risk adjustment methodologies
- Strong knowledge of ICD-10-CM coding guidelines
- Experience reviewing electronic medical records (EMRs)
- Proficiency with Microsoft Office applications
- Certified Professional Coder (CPC)
- Certified Risk Adjustment Coder (CRC)
- Certified Coding Specialist (CCS)
- Certified Coding Associate (CCA)
Nice To Haves
- Associate's or Bachelor's degree preferred
- CPC and CRC combination strongly preferred
- Additional specialty coding certifications preferred
- Medicare Advantage, Medicaid, ACA, or value-based care experience
- Experience with RADV audits and risk adjustment validation programs
- Provider education and clinical documentation improvement (CDI) experience
- Experience working for a health plan, managed care organization, ACO, IPA, or large provider group
- Familiarity with population health and quality improvement initiatives
Responsibilities
- Perform comprehensive medical record reviews to identify, validate, and capture chronic and acute conditions according to CMS and risk adjustment guidelines.
- Assign and validate appropriate ICD-10-CM diagnosis codes based on provider documentation.
- Ensure coding accuracy and compliance with CMS-HCC, HHS-HCC, and organizational risk adjustment requirements.
- Conduct retrospective, concurrent, and prospective chart reviews.
- Identify documentation gaps and communicate findings to providers and clinical teams.
- Support provider education efforts related to risk adjustment documentation and coding best practices.
- Participate in internal and external coding audits and validation activities.
- Maintain productivity and quality standards while meeting departmental goals.
- Research and interpret coding regulations, compliance updates, and CMS guidance.
- Collaborate with quality, population health, clinical operations, and provider engagement teams.
- Track coding trends and recommend opportunities for documentation improvement.
- Maintain confidentiality and comply with HIPAA requirements.
- Serve as a resource and mentor for coding specialists and clinical staff.
- Lead complex coding reviews and second-level quality audits.
- Assist with policy development, workflow optimization, and coding program initiatives.
- Analyze coding and audit results to identify trends, risks, and improvement opportunities.
- Support readiness for RADV, internal, and external audits.
- Deliver provider and staff education on coding and documentation best practices.
- Participate in cross-functional strategic projects related to risk adjustment performance.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
