Medicare Risk Adjustment Coding Specialist

American Health Partners

Medicare Risk Adjustment Coding Specialist at American Health Plans conducting coding audits and post-payment coding reviews. Involves validation audits and ensuring compliance with CMS regulations.

Posted 6/9/2026full-timeRemote • Tennessee • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes
Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement
Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured
Develop tools and metrics to improve accuracy and completeness of coding and documentation
Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards
Escalate appropriate coding audit issues to management as required
Participate in and support ad-hoc coding audits as needed
Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit
Work assigned coding projects to completion
Other duties as assigned

Requirements

What you’ll need

Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment
Follow all appropriate Federal and state regulatory requirements and guidelines, as well as company policies and procedures
Maintain established levels of production and quality standards
Knowledgeable of CMS requirements regarding claims processing and coding
Knowledgeable of coding/auditing claims for Medicare and Medicaid plans
Extensive knowledge of ICD-9 & ICD-10 diagnostic coding and auditing
Strong interpersonal skills
Excellent written and verbal communication skills
Strong organizational skills; ability to time manage effectively
Maintain confidentiality
Strong analytical and critical thinking skills required
Ability to work remotely without direct supervision
Successful completion of required training
Handle multiple priorities effectively
Education: High school or equivalent degree
Experience: 2 years’ experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system
2 years’ experience in managed healthcare environment related to claims and/or coding audits
2 years’ experience with standard coding and reference materials used in a claim setting such as CPT4, ICD10, HCPCS and others
2 years’ experience with CMS requirements regarding claims processing and coding
2 years’ experience coding/auditing claims for Medicare and Medicaid plans
Significant HCC experience (including knowledge of HCC mapping and hierarchy)
License/Certification: Coding certification required (CPC or CRC)

Benefits

Comp & perks

Affordable Medical/Dental/Vision insurance options
Generous paid time-off program and paid holidays for full time staff
TeleDoc 24/7/365 access to doctors
Optional short- and long-term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

ICD-10 codingICD-9 codingCPT4HCPCScoding auditsclaims processingHCC mappingHCC hierarchymedical record documentationrisk adjustment

Soft Skills

interpersonal skillswritten communicationverbal communicationorganizational skillstime managementanalytical skillscritical thinkingcustomer serviceconfidentialityability to work independently

Certifications

CPCCRC