Location: Boston, Hybrid
Job Summary:
The Manager, Risk Coding will manage a team of coders within a rapidly growing service that performs retrospective and prospective risk coding for Federally Qualified Health Centers and partner networks participating in C3's MassHealth ACO and Medicare ACO (Medicare Shared Savings Program) contracts. In so doing, he/she/they will use knowledge of appropriate coding, combined with expertise in claims submission processes, to improve the accuracy of documentation. This work ultimately leads to a greater understanding of the patient's complexity while ensuring accurate risk adjustment for patient care. The Manager, Risk Coding has experience in risk adjustment, outpatient primary care and/or behavioral health condition coding, billing compliance, and coding quality assurance protocols, with demonstrated experience supporting Medicare ACO risk adjustment under the CMS-HCC model (Version 28) as well as Medicaid risk adjustment under the MassHealth DxCG model. He/She/They should have prior leadership experience and the ability to provide quality assurance for all ongoing projects for the FQHCs. They will also be responsible for staff hiring, onboarding, and ongoing training, coder productivity and quality management, and the monthly delivery of coding performance reporting to participating health centers. He/she/they will report to the Senior Director, Risk Adjustment, and interface with an internal team of Provider Educators, Coding Quality and Clinical Documentation Improvement staff, Analysts, Health Center Performance Managers, as well as Billing, Population Health, and Provider staff at FQHCs.
Responsibilities:
- Serves as an expert on ICD-10-CM coding guidelines, AHA Coding Clinic Guidance, and Risk Adjustment methodologies
- Maintain quality assurance of all coding projects by conducting internal audits of charts reviewed by coding team
- Completes record review with a high degree of familiarity with common EHRs, especially Epic, NextGen, Centricity, and eCW
- Develops and delivers provider reports on findings and facilitates provider feedback loop for allowable bill modifications
- Utilizes population health reporting tools to assist in creating pre-visit coding workflows
- Develops and maintains coding educational tools
- Assesses team performance and provides feedback to employees
- Responsible for hiring and training employees and developing standard operating procedures for the coding team
- Oversees day-to-day operations and performance of coding team
- Manages day-to-day delivery of risk adjustment coding shared services for participating health centers, including monthly production targets, turnaround standards, and health center reporting commitments
- Supports C3's Medicare ACO (MSSP) risk adjustment strategy, including CMS-HCC Version 28 condition recapture, documentation integrity, and coding accuracy for Medicare attributed populations, alongside MassHealth ACO (DxCG) coding operations
- Establishes, monitors, and reports coder productivity and quality metrics (such as charts reviewed per day, coding accuracy rate, and turnaround time) and coaches team members to performance targets
- Partners with Provider Educators and coding quality staff to translate audit findings into provider education and workflow improvements, framed as educational clinical documentation improvement rather than coding directives
- Ensures coding practices align with CMS, OIG, MassHealth, and C3 compliance expectations, and escalates compliance concerns to the Senior Director, Risk Adjustment and Compliance as appropriate
- Prepares and presents monthly coding performance updates to health center leadership and internal stakeholders
- Performs other duties as assigned
Required Skills:
- 5+ years risk coding experience
- 3+ years of experience supporting Medicare ACO (MSSP or ACO REACH) or Medicare Advantage risk adjustment programs, with working knowledge of the CMS-HCC model including Version 28
- Working knowledge of Medicaid risk adjustment models, including the MassHealth DxCG model
- 5+ years medical billing experience in outpatient setting, preferably primary care, pediatrics, or behavioral health
- 2-4 years of leadership experience managing medical coding or risk adjustment coding teams, including productivity and quality management
- Billing compliance expertise
- Experience using data analysis and performance reports regarding key metrics such as risk scores, condition recapture rates, coder productivity, and coding accuracy
- Familiarity with population health management tools such as Arcadia
- In-depth knowledge of medical terminology, anatomy, physiology, and disease process
- Knowledge of electronic health record systems such as Epic, NextGen, Centricity, and eCW
- Self-starter: exercises high degree of initiative, judgement, discretion, and decision making to achieve objectives
- Proficient with MS Office
- Performs with great integrity and produces accurate work with close attention to detail, especially in the completion of final deliverables to internal and external stakeholders
Desired Other Skills:
- Expertise in both Medicaid (DxCG) and Medicare (CMS-HCC) risk adjustment models
- Experience within MassHealth ACO and Medicare ACO (MSSP) programs, including value-based care and shared savings performance
- Familiarity with Federally Qualified Health Centers
- Experience leading remote or hybrid teams supporting multiple health centers and EHR environments
- Familiarity with risk adjustment analytics vendors and reporting tools such as Milliman
- Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Qualifications:
- Bachelor's degree in business administration, healthcare administration, public health, or a healthcare-related field
- Up-to-date certifications: AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist (CCS) required; AAPC Certified Risk Adjustment Coder (CRC) preferred
** In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. ** 
