Risk Adjustment Coding Specialist II (CST/EST)

Department: Quality - Risk Adjustment

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Liz Francisco

Compensation: $70,000 - $85,000 / year

Description

We are currently seeking a highly motivated Risk Adjustment Coding Specialist to support our Houston 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 provider education and at least 3-5 years of risk adjustment experience! This position requires travel to provider offices twice a week in the Houston area.

Our Values: 

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

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 certification, CPC and CRC.
• At least 3 years of experience in risk adjustment coding and/or billing experience required.
• At least 1 year of experience with targeted provider education.
• 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
• 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 position is remotely based in the U.S. The home office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754. 

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.    
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.