Risk Adjustment Coding Specialist II - San Francisco/San Mateo/Santa ClaraDepartment: Quality - Risk Adjustment
Employment Type: Full Time
Location: 1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To: Mauriel Chaidez-Puentes
Compensation: $80,000 - $85,000 / year
DescriptionWe are currently seeking a highly motivated Risk Adjustment Coding Specialist to support our Northern California market. In this role, you will support risk adjustment efforts by conducting high-volume chart reviews to identify coding gaps, trends, and opportunities for improved accuracy for our providers. You'll translate your findings into actionable insights, creating and delivering education to providers and practice leaders while navigating complex conversations. Additionally, you'll track and report on key performance metrics-such as HCC recapture rates, AWVs, and other KPIs, helping drive provider performance and overall program success.
We are seeking candidates who have experience with risk adjustment experience, and we are open to training those without previous provider education experience! This position requires travel to provider offices up to 50% of the time in San Francisco, San Mateo, and Santa Clara.
What You'll Do- Review provider documentation of diagnostic data from medical records to verify that all Medicare Advantage, Affordable Care Act (ACO) and Commercial risk adjustment documentation requirements are met, and to deliver education to providers on either an individual basis or in a group forum, as appropriate for all IPAs managed by the company
- Review medical record information on both a retroactive and prospective basis to identify, assess, monitor, and document claims and encounter coding information as it pertains to Hierarchical Condition Categories (HCC)
- Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10- CM codes are accurately assigned and supported by clinical documentation to ensure adherence with CMS Risk Adjustment guidelines
- Interacts with physicians regarding coding, billing, documentation policies, procedures, and conflicting/ambiguous or non-specific documentation
- Prepare and/or perform auditing analysis and provide feedback on noncompliance issues detected through auditing
- Maintain current knowledge of coding regulations, compliance guidelines, and updates to the ICD-10 and HCC codes, Stay informed about changes in Medicare, Medicaid, and private payer requirements.
- Provides recommendations to management related to process improvements, root-cause analysis, and/or barrier resolution applicable to Risk Adjustment initiatives.
- Trains, mentors and supports new employees during the orientation process. Functions as a resource to existing staff for projects and daily work.
- Provides peer to peer guidance through informal discussion and overread assignments. Supports coder training and orientation as requested by manager.
- May assist or lead projects and/or higher work volume than Risk Adjustment Coding Specialist I
- Other duties as assigned
Qualifications- Required Certification/Licensure: Must possess and maintain AAPC or AHIMA certification - Certified Coding Specialist (CCS-P), CCS, or CPC.
- At least 3 years of experience in risk adjustment coding and/or billing experience required
- Reliable transportation/Valid Driver's License/Must be able to travel up to 75% of work time
- PC skills and experience using Microsoft applications such as Word, Excel, and Outlook
- Excellent presentation, verbal and written communication skills, and ability to collaborate
- Must possess the ability to educate and train provider office staff members
- Proficiency with healthcare coding software and Electronic Health Records (EHR) systems.
You're great for this role if:
- Strong billing knowledge and/or Certified Professional Biller (CPB) through APPC
- Certified Risk Adjustment Coder (CRC) and/or Risk Adjustment coding experience
- Have knowledge of Risk Adjustment and Hierarchical Condition Categories (HCC) for Medicare Advantage
- Strong PowerPoint and public speaking experience
- Ability to work independently and collaborate in a team setting
- Experience with Monday.com
- Experience collaborating with, educating, and presenting to provider teams in a face-to-face setting
Environmental Job Requirements and Working Conditions- The national target pay range for this role is $70,000 - $85,000 per year. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
- This role follows a hybridwork structure where the expectation is to work on the field and at home on a weekly basis. This position requires up to 50% travel to provider offices in San Francisco, San Mateo, and Santa Clara. There can be weeks that are fully remote, and then weeks where there are more in-office provider needs!
Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
