POSITION PURPOSEThe Manager of Coding and Risk Adjustment is responsible for leading coding operations, risk adjustment initiatives, quality assurance activities, and provider documentation improvement efforts.
This position oversees coding staff, coding quality programs, provider education initiatives, and risk adjustment performance across multiple markets and lines of business. The Manager serves as the subject matter expert for ICD-10 coding, CMS-HCC risk adjustment, Medicare Advantage, HEDIS, STARS, and coding compliance while ensuring departmental goals, coding accuracy standards, and operational performance metrics are achieved.
The Manager of Coding & Risk Adjustment collaborates closely with executive leadership, clinical providers, quality teams, and operational leaders to improve documentation integrity, maximize accurate reimbursement, support value-based care initiatives, and ensure regulatory compliance.
This position is fully remote.
DUTIES & RESPONSIBILITIESLeadership & Team Management- Lead, mentor, and develop a team of Medical Risk Coders and Chart Preparation staff.
- Conduct performance evaluations, coaching sessions, and ongoing staff development activities.
- Assist with recruitment, onboarding, training, and retention of coding team members.
- Establish productivity, quality, and performance expectations for coding staff.
- Foster a culture of accountability, collaboration, and continuous improvement.
Coding & Risk Adjustment Operations- Oversee daily coding operations to ensure accuracy, productivity, and compliance.
- Review medical records and documentation to identify appropriate ICD-10-CM diagnosis codes and CMS-HCC opportunities.
- Ensure accurate risk adjustment coding practices that support Medicare Advantage, Medicaid, and value-based care programs.
- Monitor annual HCC recapture initiatives and identify opportunities to improve RAF scores and risk adjustment outcomes.
- Remain current on diagnosis coding guidelines, CMS regulations, and risk adjustment reimbursement methodologies.
Quality Assurance & Compliance- Maintain departmental coding accuracy standards of 95% or greater.
- Conduct routine coding audits and quality reviews to ensure coding integrity and compliance.
- Develop corrective action plans and provide feedback based on audit findings.
- Monitor compliance with CMS, Medicare, Medicaid, HIPAA, and organizational policies.
- Support readiness for internal, external, health plan, and regulatory audits.
Provider Documentation Improvement- Provide education and training to providers regarding coding accuracy, risk adjustment, HCC documentation, HEDIS and STARS coding guidelines.
- Review provider documentation and identify opportunities for improvement.
- Develop training materials and coding reference tools to improve documentation quality.
- Partner with clinical leadership to enhance provider documentation practices and coding performance.
- Provide real-time coding and documentation support to providers and clinical teams.
Reporting & Analytics- Develop and monitor departmental reports related to:
- Coding accuracy
- Audit performance
- HCC recapture rates
- Provider performance
- Productivity metrics
- Quality outcomes
- Analyze coding trends and identify opportunities for operational improvement.
- Assist leadership in developing performance goals and strategic initiatives.
- Implement data-driven recommendations to improve coding outcomes and financial performance.
Operational Excellence- Develop and implement workflow improvements that increase efficiency and quality.
- Support implementation of new coding processes, technologies, and system enhancements.
- Collaborate with cross-functional departments to improve coding operations and performance.
- Drive scalable infrastructure and process improvements to support organizational growth.
Other Responsibilities- Maintain confidentiality of Protected Health Information (PHI).
- Conduct all activities professionally and in accordance with company policies.
- Participate in quality improvement initiatives.
- Perform additional duties as assigned.
KEY PERFORMANCE INDICATORS (KPIs)- Coding Accuracy 60; 95%
- Audit Accuracy 60; 95%
- HCC Recapture Rate Achievement
- Coding Productivity Goals
- Provider Training Completion Rates
- Documentation Improvement Outcomes
- Regulatory Compliance Standards
- Team Productivity and Engagement
- Coding Turnaround Time
- Quality Audit Findings and Remediation Success
SKILLS & QUALIFICATIONS- Five (5) years of ICD-10 coding experience.
- Three (3) years of Medicare Advantage and Risk Adjustment coding experience.
- Two (2) years of leadership, mentoring, supervisory, or management experience.
- Experience conducting coding audits and quality assurance reviews.
- Experience providing provider education and documentation improvement support.
- Strong knowledge of:
- ICD-10-CM Coding
- CMS-HCC Risk Adjustment Methodology
- Medicare Advantage
- Medicaid Risk Adjustment
- HEDIS
- STARS
- RAF Scoring
- Provider Documentation Improvement (PDI)
- CMS Documentation Guidelines
- Knowledge of EMR platforms and healthcare technology systems.
- Knowledge of claims, encounters, billing processes, and healthcare reimbursement models.
- Strong analytical, organizational, and problem-solving skills.
- Excellent written and verbal communication skills.
- Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
EDUCATION, LICENSES, & CERTIFICATIONS- High School Diploma or GED required.
- Bachelor9;s degree in healthcare administration, health information management, business administration, nursing, or a related field preferred.
- Active Certified Risk Adjustment Coder (CRC) credential required.
- CPC, CCS, RHIT, RHIA, or additional coding certification preferred.
- Experience with Salesforce or other CRM platforms preferred.
BENEFITS & TOTAL REWARDS- Paid Orientation and Training
- Insurance - Medical, Dental, Vision, and Life
- 401k Plan - 3% match
- Employee Assistance Program
- Tuition Reimbursement
- Continued Education Support
- Mileage Reimbursement (if applicable)
- Referral Bonuses
- Paid Holidays (9 days)
- Paid Time Off (20 days)
- Paid Volunteer Hours
CHARACTER & COMPETENCIES- Courage - To have the courage to do the right thing at the right time.
- Ownership - To take ownership of every issue you touch.
- Respect - To respect yourself, co-workers, and for those whom you care.
- Excellence - To be excellent in all that you do.
- Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
- Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethics; Upholds organizational values.
- Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
- Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others9 ideas and tries new things.
- Judgement - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
- Problem-Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations; Uses reason even when dealing with emotional topics.
- Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
- Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others9 views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone9s efforts to succeed.
PHYSICAL DEMANDS & WORK ENVIRONMENT- Occasionally required to stand.
- Occasionally required to walk.
- Continually required to sit.
- Occasionally required to climb, balance, bend, stoop, kneel, or crawl.
- Continually required to talk or hear.
- While performing the duties of this job, the noise level in the work environment is usually moderate.
- May occasionally lift and /or move more than 30 pounds.
- Must be able to physically perform the essential duties of the position which include lifting 30 lbs., transporting materials, stooping, kneeling, crouching, reaching, use of hands, balancing, walking, standing, talking, hearing, and typing.
