HCC Coding Leader - Risk Adjustment

Obsidian; San Francisco (CA); On-site; USD 170,000 - 210,000; Full time

Job summary

Mercor is seeking an experienced Risk Adjustment and HCC Coding leader to guide operations across Medicare Advantage, Medicaid, and ACA programs. You will review AI-generated risk adjustments, ensure regulatory compliance, and oversee RADV audit prep.

A strong background in CMS-HCC/ACA methodologies, ICD-10-CM, and documentation insights is essential. You will collaborate with clinical, coding, and compliance teams to improve data capture, coding accuracy, and risk score integrity while guiding

Qualifications

• 5+ years in risk adjustment coding or Medicare Advantage coding operations, with leadership experience.
• Deep expertise in CMS-HCC, RxHCC and ACA HHS-HCC risk adjustment methodologies.
• Strong knowledge of ICD-10-CM guidelines for HCC risk adjustment.
• Experience with RADV audit preparation and CMS compliance requirements.
• Familiarity with RAPS and EDGE submission processes.

Responsibilities

• Lead risk adjustment and HCC coding operations across Medicare Advantage, Medicaid, and ACA programs.
• Evaluate AI-generated HCC coding assignments for clinical accuracy and regulatory compliance.
• Review medical records to ensure complete capture of HCC-eligible conditions.
• Conduct chart reviews for risk score optimization.
• Manage RADV audit preparation and response processes.
• Monitor KPIs such as HCC capture rates and chart retrieval rates.
• Collaborate with clinical, coding and compliance teams to improve documentation and coding.
• Ensure CMS risk adjustment guidelines and Official Coding Guidelines are followed.
• Annotate AI outputs and provide structured coding feedback for training datasets.

Skills

Risk adjustment coding

CMS-HCC

RADV audit

RAPS & EDGE

Clinical documentation review

Education

CRC/CCS/CPC/RHIA credential

Tools

Risk adjustment analytics platforms

Chart retrieval systems

Job description

Mercor is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Risk Adjustment and HCC Coding leaders to evaluate AI tools designed to improve risk score accuracy and coding completeness in Medicare Advantage, Medicaid managed care, and ACA markets. Your expertise in hierarchical condition category (HCC) methodology, RADV audit preparation, and risk adjustment coding will directly shape AI systems that enhance documentation capture and risk score integrity.

Responsibilities

• Lead risk adjustment and HCC coding operations across Medicare Advantage, Medicaid, and/or ACA risk adjustment programs.




• Evaluate AI-generated HCC coding assignments and risk adjustment recommendations for clinical accuracy and regulatory compliance.




• Review medical records to ensure complete and accurate capture of HCC-eligible conditions supported by clinical documentation.




• Conduct and oversee retrospective and prospective chart reviews for risk score optimisation.




• Manage RADV (Risk Adjustment Data Validation) audit preparation and response processes.




• Monitor risk adjustment KPIs including HCC capture rates, risk score accuracy, and chart retrieval rates.




• Collaborate with clinical, coding, and compliance teams to improve documentation and coding for risk adjustment purposes.




• Ensure compliance with CMS risk adjustment guidelines (RAPS, EDGE submissions) and Official Coding Guidelines.




• Annotate AI outputs and provide structured coding feedback to support AI training datasets.

Requirements

• 5+ years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, with at least 2 years in a leadership role.




• Deep expertise in CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies.




• Strong knowledge of ICD-10-CM coding guidelines as applied to HCC risk adjustment.




• Experience with RADV audit preparation and CMS compliance requirements.




• Familiarity with RAPS and EDGE submission processes.




• Exceptional written and verbal English communication skills.




• High attention to detail with the ability to identify coding inaccuracies and documentation gaps in AI-generated outputs.

Preferred Qualifications

• CRC (Certified Risk Coder), CCS, CPC, or RHIA credential.




• Experience with risk adjustment analytics platforms and chart retrieval systems.




• Background in health plan, Medicare Advantage organisation, or value-based care setting.




• Familiarity with AI-assisted HCC coding tools and comfort evaluating AI-generated risk adjustment content.




• Experience presenting risk adjustment performance to actuarial or executive teams.

Why Join?

• Contribute to the development of frontier AI systems in healthcare.




• Collaborate with a world-class AI research organisation.




• Gain exposure to cutting-edge AI workflows in risk adjustment and value-based care.




• Opportunity to work on high-impact projects shaping the future of healthcare AI.