Risk

• Review participant medical records and provider documentation to identify, validate, and code risk-adjustable diagnoses in accordance with CMS-HCC v24 and v28 guidelines.
• Ensure complete, accurate, and compliant ICD-10-CM coding with a primary focus on concurrent and retrospective reviews (with flexibility for pre-visit planning as needed).
• Draft and submit compliant provider queries to clarify documentation and support accurate coding.
• Track and follow through on open queries—engaging with providers, monitoring responses, and closing them out appropriately.
• Apply strong critical thinking skills to resolve complex documentation and coding scenarios.
• Maintain clear, professional communication with providers and internal teams to support documentation completeness.
• Stay current with CMS, OIG, and industry regulations related to risk adjustment and coding compliance.
• Support accurate and compliant documentation for PACE participants in a remote environment.

Certified Risk Adjustment Coder

Senior Payment Fraud – Risk Specialist

Coding Team Lead, HCC Risk Adjustment Coding

Senior Group Risk Specialist – Technology Risk

Senior Manager, Group Risk – Operational Risk Profiles

Executive Risk Control Specialist – Large Accounts