SENIOR RISK ADJUSTMENT SPECIALIST (2801)

VIVANT HEALTH•Sacramento, CA

20h•Onsite

About The Position

The Senior Risk Adjustment Factor (RAF) Specialist supports Vivant’s risk adjustment initiatives within the IPA’s Medicare Advantage line of business. This advanced role ensures accurate and complete documentation and coding of diagnoses to optimize member Risk Adjustment Factor (RAF) scores, supporting quality patient care and accurate reimbursement under CMS guidelines. The Senior RAF Specialist collaborates closely with providers, coders, and care management teams to identify and implement opportunities for RAF improvement through education, chart reviews, and data analysis.

Requirements

Minimum of 5-8 years of experience in Risk Adjustment, HCC coding, or Medicare Advantage operations.
Strong knowledge of ICD-10, HCC risk adjustment models, CMS guidelines, and Medicare Advantage programs.
Proficiency in EMR/EHR systems, risk adjustment analytics platforms, and Microsoft Office Suite (Excel, Power BI preferred).
Ability to analyze data, identify trends, and develop actionable insights.
Excellent communication, both oral and written, and interpersonal skills for provider education and collaboration.
Excellent attention to detail and ability to document information accurately.
Excellent active listening skills.
Ability to solve advanced-level problems with minimal supervision.
Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
Ability to provide and receive constructive job and/or industry related feedback.
Ability to maintain confidentiality and appropriately share information on a need-to-know basis.
Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
Ability to consistently deliver excellent customer service.
Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
Ability to work independently as well as in a team environment.
Ability to present self in a professional manner and represent the Company image.
Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
Demonstrate commitment to the organization’s mission.
Must have the ability to quickly learn and use new software tools.
Must have advanced-level skills using e-mail applications.
High School Diploma or GED required.
Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), Certified Professional Medical Auditor (CPMA), or equivalent credential required.
Must have an active and unrestricted California Driver’s license.
Must have auto insurance and reliable transportation.

Nice To Haves

3-5 years of Independent Physician Association (IPA) or health plan environment preferred.
Cozeva experience preferred.
Associate’s or Bachelor’s degree in Health Information Management, Health Administration, Nursing, or related field preferred.
Typing speed of 40 wpm or more is a plus.

Responsibilities

Own coding and Monthly Membership Report reconciliation.
Lead provider education (training, specialty tip-sheets, and targeted on-on-one feedback).
Run/own audit program (sampling, error trending, corrective action, and RADV-readiness support).
Lead audit pass rates, sustained provider documentation improvement, RAF accuracy lift, reduced audit risk, and education completion/impact.
Review and analyze clinical documentation and diagnosis coding to ensure compliance with CMS-HCC (Hierarchical Condition Category) guidelines.
Monitor and report RAF score trends across assigned providers, physician groups, and Medicare populations.
Conduct retrospective and prospective chart reviews to identify coding gaps, suspected conditions, and missed opportunities.
Partner with provider offices to ensure accurate submission of encounter data and supplemental claims.
Work collaboratively with health plan and IPA coding teams to reconcile risk score discrepancies and validate data accuracy.
Support provider education programs on compliant documentation and coding practices (HCC, ICD-10, and CMS Risk Adjustment methodology).
Compile RAF performance dashboards and support audit and reconciliation processes related to Medicare risk adjustment.
Participate in outreach campaigns to ensure timely completion of annual wellness visits and other risk-capture opportunities.
Stay current with CMS updates, HCC model changes, and risk adjustment regulatory requirements.
Assist in developing workflow improvements for documentation, coding, and data submission.
Performs related duties consistent with the scope and intent of the position.
Regular attendance.
Travel as required.
Enforces Company policies and safety procedures.
Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
Maintain IPA, Health Plan compliance standards.