Risk Adjustment Coding Specialist

El Monte, CA 91731

Employment Type: Direct Job Category: Medical Coder Job Number: 46686


The Risk Adjustment Coding Specialist is responsible for reviewing provider documentation of diagnostic data from medical record to verify that all Medicare Advantage 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.


  • Comply with department policies and procedures.
  • Responsible for the day-to-day department operations, monitoring and compliance of all risk adjustment activities and performance for all IPAs.
  • 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
  • Identifies revenue, reimbursement, and educational opportunities while remaining compliant with state and federal regulations.
  • Assess adequacy of documentation and query providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
  • Ensures that rendered physician services for claim submission and subsequently payment are as accurate as possible while complying with regulatory guidelines including CMS, DHS, and OIG.
  • Select correct ICD code assignment by proficient analysis and translation of diagnostic statements, physicians' orders, and other pertinent documentation.
  • Complies with all aspects of Coding, abides by all ethical standards, and adheres to official coding guidelines. Conducts physician chart audits to identify incorrect coding, prepares reports of findings and any compliance issues.
  • Interacts with physicians regarding billing and 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.
  • Responsible for performing training and coordinating educational seminars for all risk adjustment
  • Attend relevant trainings and technical content webinar training as required
  • Reporting generate and maintain accurate weekly/monthly/quarterly report of activities
  • Attend to health plans, provider, and interdepartmental calls in accordance with exceptional customer service; maintain professional and appropriate behavior (actions/verbal) at all times
  • Performs other duties, projects and actions as assigned in a professional manner, utilizing time and resources efficiently


  1. Minimum Education: High School diploma or Equivalent; BS/BA preferred
  2. Required Certification/Licensure: Must possess and maintain AAPC or AHIMA certification - Certified Risk Adjustment Coder (CRC) & Certified Coding Specialist (CCS-P), CCS, CPC
  3. Minimum of two years experienced in healthcare reimbursement or revenue cycle related position or five years of overall experience in healthcare.
  4. Knowledge of Risk Adjustment and Hierarchical Condition Categories (HCC) and Medicare Advantage reimbursement a plus.
  5. Must have an excellent understanding of medical terminology, disease process and anatomy and physiology. Ability to understands and explain data reports in different ways to practitioners
  6. Desired Experience: ICD-10, Microsoft Power Point, CPT/HCPCS Coding, Medical Terminology, working knowledge of managed care and health plan standards on Risk Adjustment & HCC Coding
  7. Must have an excellent understanding of CPT coding within a Primary Care environment.
  8. Demonstrated flexibility, organization, and appropriate decision-making under challenging situations.
  9. Demonstrated skill and experience in effectively collaborating with team members & others using oral, written, and interpersonal communications.
  10. Demonstrated PC skills in Microsoft Word, Excel, and/or Microsoft Access.
  11. Excellent analytical critical reasoning and interpersonal communication skill.
  12. Must exhibit efficiency, collaboration, candor, openness, and results orientation
  13. Excellent presentation, verbal and written communication skills, and ability to collaborate with co-workers, senior leadership, and other management.
  14. Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
  15. Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
  16. Must possess the ability to educate and train provider office staff members
  17. Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
  18. Must be ethical and possess the ability to remain impartial and objective.
  19. Must be able to travel at least 75% of work time.
  20. Personal & Professional Qualities
  • Punctuality, Creativity, Self-motivation
  • Professional appearance and conduct.
  • Conceptual and big picture understanding
  • Able to function independently under time constraints
  • Willing to learn and develop new responsibilities and skills.
  • Good organization, critical thinking, and problem solving skills.
  • Must be detail-oriented and able to work autonomously but also as a team member
  • Should have strong communication and customer service skills and respect for confidentiality.

STATUS: Non-Exempt Position

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.

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