Senior Risk Adjustment Coder (Remote)

Summary:

The Senior Risk Adjustment Coder is responsible for accurate and compliant risk adjustment coding through retrospective documentation auditing, provider-facing education, and two-sided chart reviews. This role partners closely with physicians, practice staff, and operational teams to improve documentation specificity, support new PCP onboarding, reinforce ongoing education, and enhance RAF accuracy, compliance, and revenue integrity across targeted populations.

Essential Duties and Responsibilities:

• Conduct retrospective documentation audits to validate diagnosis capture, coding accuracy, and compliance with CMS, ICD-10-CM, and organizational guidelines

• Perform two-sided chart reviews to identify documentation gaps, unsupported diagnoses, and opportunities for recapture and coding specificity

• Evaluate medical records for complete and compliant support of submitted diagnoses, including assessment of M.E.A.T. criteria where applicable

• Develop and deliver physician education focused on documentation integrity, HCC capture, coding guidelines, and audit findings

• Support new PCP onboarding by providing education, training resources, and one-on-one guidance on risk adjustment documentation and coding expectations

• Provide continuous education to PCPs and practice teams based on audit trends, regulatory updates, and identified documentation improvement opportunities

• Track audit outcomes, report findings, and collaborate with operational and clinical stakeholders to improve coding accuracy, documentation quality, and program performance

• Serve as subject matter expert on PBACO risk adjustment tools, including pre-visit and concurrent capabilities, and risk suspecting

• Partner with the Performance Enhancement Series (PES) department to drive improvement in risk adjustment for identified practices

Measurable Goals/Objectives:

• Achieve target audit completion volumes and turnaround times for retrospective and two-sided chart reviews

• Improve HCC recapture and documentation specificity through provider education and targeted audit feedback

• Maintain compliance with applicable risk adjustment coding, documentation, and audit requirements across assigned programs

• Increase provider engagement and education completion for new PCP onboarding and ongoing documentation improvement efforts

Supervisory Responsibilities:

• No direct supervisory responsibilities

Competencies:  To perform the job successfully, an individual should demonstrate the following competencies:

• Strong knowledge of HCC methodology including CMS-HCC, HHS-HCC, CDP logics; ICD-10-CM coding guidelines, CMS risk adjustment requirements, and compliant documentation standards

• Ability to audit complex medical records, identify documentation gaps, and apply coding guidance accurately and consistently

• Excellent communication and education skills with the ability to present audit findings and documentation guidance to physicians and practice staff

• Strong organizational skills and the ability to manage multiple audits, education initiatives, and deadlines in a fast-paced environment

• Proficiency with EHR systems, coding tools, audit workflows, and Microsoft Office applications, especially Excel and PowerPoint

• Safety and Security - Uses equipment and materials properly.

• Attendance/Punctuality - Is consistently at work and on time.

• Knowledge of medical records work procedures.

• Knowledge of computer applications.

• Knowledge of medical terminology.

• Knowledge of legal and ethical consideration related to patient information.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Deep knowledge of HCC models, CMS risk adjustment principles, and compliant documentation and coding standards. Minimum 4+ years of risk adjustment coding and/or auditing experience required, including provider-facing education responsibilities. CRC, CPC, or CDEO certification required; multiple certifications preferred. Bachelor’s degree preferred. Experience in Medicare Advantage, value-based care, managed care, and/or provider education is strongly preferred.