CMS Risk Adjustment Coding Specialist

CenCal Health; Santa Barbara (CA); On-site; USD 43,000 - 62,000; Full time

Job summary

The CenCal Health Risk Adjustment Coder Specialist ensures accurate medical diagnosis data submission to CMS for the Medicare Advantage D-SNP line of business. This role optimizes diagnosis documentation, identifies barriers to appropriate risk adjustment, oversees outsourced vendor coding for CMS compliance, and educates providers on accurate coding to support compliant risk adjustment.

Responsibilities include reviewing records for CMS-HCC alignment, supervising vendor coding activities,

Qualifications

• Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or a closely related field.
• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or equivalent certification.
• Three (3) plus years of risk adjustment coding experience in Medicare Advantage, ACA, or Medicaid.
• Three (3) plus years of experience in a health plan or managed care setting.

Responsibilities

• Review records to identify, validate, and ensure accurate capture of CMS-HCC risk codes.
• Oversee vendor coding activities, monitor quality, and resolve discrepancies.
• Collaborate with provider groups to resolve coding questions and improve chart review.
• Develop and deliver education on CMS Risk Adjustment guidelines and documentation.
• Identify documentation gaps and coding trends to strengthen risk adjustment outcomes.
• Support RADV audits by preparing documentation and responding to findings.
• Maintain updated coding guidance reflecting CMS risk model updates.
• Analyze coding data to identify patterns and track vendor performance.
• Lead updates to coding guidelines based on CMS changes.
• Stay current on Medicare Advantage, D-SNP, RADV requirements, and best practices.

Skills

CMS-HCC knowledge

ICD-10-CM guidelines

Documentation accuracy

Provider education

Communication skills

Excel skills

Vendor performance monitoring

HIPAA compliance

Analytical skills

Education

Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or related field

CPC or CRC certification

Tools

Microsoft Word

Microsoft PowerPoint

Microsoft Excel

Job description

The CenCal Health Risk Adjustment Coder Specialist ensures accurate medical diagnosis data submission to CMS for the Medicare Advantage D-SNP line of business. This role optimizes diagnosis documentation, identifies barriers to appropriate risk adjustment, oversees outsourced vendor coding for CMS compliance, and educates providers on accurate coding to support compliant risk adjustment.

Responsibilities include reviewing records for CMS-HCC alignment, supervising vendor coding activities,