Principal Risk Adjustment Compliance Leader

Blue Shield of California; California (MO); On-site; USD 150,000 - 230,000; Full time

Job summary

Blue Shield of California is seeking a Risk Adjustment Compliance Specialist, Principal to ensure compliance across ACA Marketplace, Medicaid, and Medicare Advantage lines. The role involves auditing, monitoring, and evaluating risk adjustment processes, identifying non-compliance, and recommending corrective actions.

Collaboration with internal teams and external partners is essential to uphold data integrity and implement compliance programs.

Qualifications

• Requires a college degree or equivalent experience in health care/related field
• Certification: CRC/CPC/CCS or equivalent credential is required
• 10+ years of risk adjustment, healthcare compliance, coding, or related experience
• Strong knowledge of ICD-10-CM, CMS-HCC, HHS-HCC, RADV audit standards, and compliance requirements
• Experience with data analysis, auditing, and reporting in healthcare
• Excellent written and verbal communication skills; detail-oriented and able to manage multiple priorities
• Proficiency in Microsoft Office and healthcare software applications
• Experience with ACA Marketplace (HHS-HCC) and/or Medi-Cal/Medicaid risk adjustment preferred
• CHC certification preferred

Responsibilities

• Audit risk adjustment data submissions for regulatory compliance (CMS, OIG, HHS)
• Monitor changes in risk adjustment guidelines and communicate updates
• Analyze processes to identify gaps and non-compliance areas
• Prepare reports and presentations on audit findings and risks
• Collaborate with coding, clinical, and data management teams for documentation
• Assist in training programs related to risk adjustment compliance
• Support regulatory reporting and respond to inquiries from auditors
• Maintain documentation of compliance activities per policy
• Participate in risk adjustment projects as a compliance expert
• Provide strategic guidance to align programs with company goals
• Build internal and external relationships to support teams
• Develop and execute corrective action plans for issues
• Assess potential compliance risks and contribute to mitigation strategies

Skills

Communication skills

Attention to detail

Analytical thinking

Multitasking

Education

Bachelor's degree in health care administration or related field

CRC/CPC/CCS or equivalent certification

CHC certification preferred

Tools

Microsoft Office

Healthcare software

Job description

Blue Shield of California is seeking a Risk Adjustment Compliance Specialist, Principal to ensure compliance across ACA Marketplace, Medicaid, and Medicare Advantage lines. The role involves auditing, monitoring, and evaluating risk adjustment processes, identifying non-compliance, and recommending corrective actions.

Collaboration with internal teams and external partners is essential to uphold data integrity and implement compliance programs.