Risk Adjustment Coder Specialist

Central Coast Salary Range: $31.17 - $45.20

Job Summary

The Risk Adjustment Coder Specialist ensures accurate medical diagnosis data submission to CMS for CenCal Health Medicare Advantage D-SNP line of business. This role optimizes diagnosis documentation, identifies barriers to appropriate risk adjustment, oversees outsourced vendor coding for CMS compliance, and partners with provider outreach teams to educate providers on accurate and comprehensive medical coding.

Duties & Responsibilities

• Perform reviews of records to identify, validate, and ensure accurate capture of diagnosis codes aligned with CMS-HCC, HHS-HCC, ICD-10-CM and applicable risk adjustment requirements.
• Oversee vendor coding activities, including monitoring work quality, reviewing vendor coded records, validating findings, resolving discrepancies, and providing feedback to vendors and internal leadership.
• Collaborate with provider groups and internal departments to resolve coding questions, clarify documentation, improve chart review processes, and promote compliant risk adjustment practices.
• Develop and deliver provider and clinical staff education on CMS Risk Adjustment guidelines; compliant documentation practices, diagnosis specificity, and accurate coding standards.
• Identify documentation gaps, coding trends, and opportunities for improvement, and partner with clinical, quality, analytics, compliance, and provider facing teams to strengthen risk adjustment outcomes.
• Support internal, external, and CMS Risk Adjustment Data Validation (RADV) audits by preparing documentation, reviewing audit samples, validating diagnosis support, and assisting with response activities.
• Maintain and update internal coding guidance, workflows, reference materials, and job aids to reflect CMS risk model updates, ICD-10-CM changes, and organizational process improvements.
• Analyze coding and documentation data to identify patterns, measure program effectiveness, track vendor performance, and support reporting for leadership and operational stakeholders.
• Lead efforts to maintain updated coding guidelines based on CMS risk model updates and changes.
• Maintain current knowledge of Medicare Advantage, D-SNP, CMS risk adjustment regulations, RADV requirements, and industry best practices to support ongoing compliance and program integrity.
• Serves as coding resource and subject matter expert on risk adjustment diagnosis coding, documentation requirements, coding guideline interpretation, and CMS regulatory updates.

Knowledge/Skills/Abilities

• Expert knowledge of CMS-HCC or HHS-HCC risk adjustment models, including diagnosis to HCC mapping, hierarchy logic and annual model updates issued by CMS.
• Strong working knowledge of ICD-10-CM Official Guidelines for Coding, and Reporting, medical terminology, and accepted risk adjustment coding and documentation standards.
• Ability to identify unsupported, unspecified, inaccurate, deleted, or duplicate diagnosis codes and recommend appropriate corrections in accordance with coding and compliance requirements.
• Demonstrated skill in identifying documentation gaps, missed chronic conditions, coding trends, and provider education opportunities that support accurate and complete risk adjustment reporting.
• Excellent written, verbal, and interpersonal communication and presentation skills. including the ability to explain complex coding and risk adjustment concepts to providers, clinical teams, vendors, and internal stakeholders.
• High Proficiency in Microsoft Office applications, including Word, PowerPoint, Outlook, and Intermediate Excel skills.
• Ability to monitor outsourced coding vendor performance, review quality results, communicate audit findings, track recurring issues, and escalate concerns to leadership when needed.
• Understanding of CMS Medicare Regulatory expectations, Risk Adjustment Data Validation (RADV) audit concepts, overpayment risk, compliance controls, and documentation standards to support submitted diagnoses.
• Ability to develop and deliver effective provider and staff education related to diagnosis documentation accuracy, condition of specificity, chronic condition recapture, and risk adjustment best practices.
• Strong analytical and problem-solving skills, including the ability to interpret coding accuracy results, identify root causes, evaluate patterns, and recommend practical process improvements.
• Ability to establish and maintain positive professional working relationships, with providers, vendors, internal departments, and external partners while promoting a culture of coding accuracy and compliance.
• Ability to maintain confidentiality, protect member health information, and perform all work in accordance with HIPAA, organizational policies, and applicable regulatory requirements.

Education & Experience

• Bachelor's degree in Healthcare Administration, Nursing, Health Information Management, or a closely related field.
• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or equivalent certification.
• Three (3) plus years of risk adjustment coding experience in either Medicare Advantage, Affordable Care Act, or Medicaid.
• Three (3) plus years of experience in a health plan or managed care setting.