Senior Risk Adjustment Operations Specialist

Clever Care Health Plan•Huntington Beach, CA

4d•$81,500 - $100,000•Hybrid

About The Position

The Senior Risk Adjustment Operations Specialist serves as a key liaison among risk adjustment coders, primary care providers (PCPs), provider office staff, and internal stakeholders. The role translates coding and documentation findings into practical, provider-facing education and operational follow-up that improves HCC capture, recapture, documentation specificity, and coding accuracy. This position supports risk adjustment performance by helping provider offices strengthen clinical documentation practices, close documentation gaps, and integrate sustainable workflows at the point of care.

Requirements

Bachelor’s degree in healthcare administration, health information management, nursing, business, or a related field; equivalent relevant experience may be considered.
Five or more years of progressive experience in Medicare Advantage risk adjustment, HCC coding operations, clinical documentation improvement, provider education, or a related healthcare function.
Demonstrated knowledge of ICD-10-CM coding, CMS-HCC risk adjustment, documentation requirements, and compliant provider education practices.
Experience working directly with physicians, advanced practice clinicians, coding professionals, and provider office staff.
Proficiency with Microsoft Office applications and experience using risk adjustment, coding, electronic health record, provider portal, or reporting platforms.

Nice To Haves

Current professional coding credential such as CPC, CCS, CCS-P, CRC, RHIA, or RHIT is strongly preferred; CRC or comparable risk adjustment credential is preferred.
Health plan, IPA, medical group, MSO, or provider-practice experience supporting Medicare Advantage populations.
Experience conducting provider-facing education, field visits, virtual training, and performance improvement follow-up.
Knowledge of CMS RADV, coding audit processes, encounter data, chart review operations, and HCC recapture workflows.
Experience developing training materials, job aids, standard operating procedures, and action plans.
Bilingual capability aligned with the needs of the provider network is a plus.

Responsibilities

Serve as the primary operational link between coding teams and assigned PCP practices.
Facilitate timely, clear, and actionable communication regarding coding findings, documentation opportunities, and recurring provider-office barriers.
Deliver individual and group education to PCPs, advanced practice clinicians, and office staff on compliant HCC documentation, MEAT principles, condition specificity, annual recapture, and documentation requirements that support accurate coding.
Review coder feedback and translate technical findings into provider-friendly guidance.
Coordinate case-level follow-up, clarify documentation questions, and track resolution of identified issues without directing or influencing unsupported diagnosis coding.
Identify patterns in incomplete, nonspecific, conflicting, or insufficient documentation and recommend practical improvements to workflows, templates, visit preparation, and follow-up processes.
Use risk adjustment reports, suspect conditions, recapture lists, and coding trends to prioritize provider outreach and education while promoting accurate and complete documentation of conditions evaluated, assessed, treated, or monitored during the encounter.
Assess front- and back-office processes that affect pre-visit planning, annual wellness visits, chart preparation, encounter submission, medical record retrieval, and response to coding queries.
Partner with practices on corrective action plans and monitor progress.
Analyze provider-level and coder-level findings to identify training needs, recurring documentation deficiencies, coding variances, and operational risks.
Summarize themes and recommend targeted interventions.
Support coding quality assurance activities and ensure education aligns with current ICD-10-CM Official Guidelines for Coding and Reporting, CMS risk adjustment requirements, organizational policies, and ethical coding standards.
Maintain complete records of provider education, outreach, feedback, attendance, issue resolution, and corrective actions.
Assist with internal audits, compliance reviews, and CMS RADV or other regulatory audit readiness activities.
Collaborate with Risk Adjustment, Quality/Stars, Provider Relations, Clinical, Compliance, IT/Data Analytics, and vendor partners to resolve issues and improve provider performance.
Participate in risk adjustment initiatives, provider campaigns, system implementations, process redesign, and special projects.
Assist with testing reports and workflows and provide operational feedback.
Develop and maintain standard work, job aids, training materials, FAQs, and provider-facing tools.
Recommend process improvements that improve accuracy, timeliness, provider experience, and scalability.