Risk Adjustment Auditor & Educator (CMS)

SilverSummit Healthplan; Nevada; Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene is seeking a senior risk adjustment specialist to lead provider education and CMS data validation across assigned markets. You will analyze MRA data, identify patterns, and coordinate with multiple internal teams to ensure accurate coding and compliant CMS risk adjustments.

The role requires 5+ years in hospital/physician/MCO coding, CPC/CCS with CPMA and CRC certifications, and strong communication and organizational skills.

Qualifications

• Bachelor’s degree or equivalent experience required.
• 5+ years in hospital, physician setting or Managed Care Organization as a medical coder.
• 2+ years coding experience with Medicare risk adjustment (HCC Coding).
• Teaching/training/educator role required; provider education preferred.
• Licenses/certifications: CPC or CCS required; CPMA within first year; CRC by second year.

Responsibilities

• Conduct provider education and training on risk adjustment to ensure accurate CMS payments and improve care quality.
• Analyze MRA data to identify patterns and develop provider/market interventions.
• Serve as subject matter expert for risk adjustment coding and CMS data validation.
• Coordinate with Provider Relations, Quality and Medical Director to ensure CMS risk adjustment compliance.
• QA auditing of ICD-9/ICD-10 coding and communicate results with retraining suggestions.
• Fulfill additional risk adjustment audit requests and other duties as assigned.

Skills

Managed Care experience

HCC methodology knowledge

Provider education/training

Clear communication

Organizational skills

Education

Bachelor's degree or equivalent experience

Job description

Centene is seeking a senior risk adjustment specialist to lead provider education and CMS data validation across assigned markets. You will analyze MRA data, identify patterns, and coordinate with multiple internal teams to ensure accurate coding and compliant CMS risk adjustments.

The role requires 5+ years in hospital/physician/MCO coding, CPC/CCS with CPMA and CRC certifications, and strong communication and organizational skills.