Risk Adjustment Coder II

Harris Health; Houston (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Community Health Choice is a nonprofit managed care organization serving Texas. The Risk Adjustment Coder II will review complex medical records, code chronic conditions, and map to HCCs under CMS guidelines.

The role supports Commercial and Medicare risk adjustment programs and helps ensure accurate documentation and coding. The coder will contribute to trainings, audits, and collaboration across departments to improve documentation quality and compliance.

Qualifications

• Bachelor’s Degree or 5+ years of risk adjustment experience in lieu of a degree.
• AHIMA/AAPC certified coder with Medical Billing and Coding certification (CPC/CRC/COC/CCS/CCS-P).
• 3–5 years of Commercial or Medicare risk adjustment coding experience.
• Proficiency with Microsoft 365 (Word, Excel, Outlook, SharePoint, Teams).
• Inpatient/outpatient clinical documentation improvement experience is preferred.

Responsibilities

• Provide advanced complex medical records reviews and code all relevant diagnoses using ICD-10 for risk adjustment programs.
• Map diagnoses to Hierarchical Condition Categories (HCCs) per CMS guidelines and internal policies.
• Identify opportunities to improve documentation and coding accuracy; present recommendations to leadership.
• Meet productivity and quality standards as set by supervision.
• Stay current with coding standards and CMS changes to ensure ongoing compliance.
• Collaborate with multiple departments on risk adjustment initiatives and trainings.

Skills

Microsoft 365

Education

Bachelor’s Degree

AHIMA/AAPC Certification

Medical Billing and Coding Certification (CPC/CRC/COC/CCS/CCS-P)

Tools

Microsoft 365

Job description

About Us

Community Health Choice, Inc. (Community) is a non‑profit managed care organization licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 members with programs including the Medicaid State of Texas Access Reform (STAR) program for low‑income children and pregnant women; the Children’s Health Insurance Program (CHIP) for the children of low‑income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR; Health Insurance Marketplace Plans offering individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre‑existing conditions; and the Community Health Choice HMO D‑SNP, a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid. Improving members’ experiences is at the heart of every Community position.

Job Summary

The Risk Adjustment Coder II provides advanced support for complex medical record reviews to ensure the correct capture of chronic conditions and complexities in order to calculate a patient’s risk score. The role maps diagnoses to Hierarchical Condition Categories (HCCs) while adhering to CMS guidelines and internal coding policies for Commercial Risk Adjustment, Medicare Risk Adjustment, and HHS and Medicare RADV systems. The coder serves as a subject‑matter expert for risk adjustment and assists in developing team trainings, quality assurance audits, and collaboration with multiple departments across the organization.

Job Specifications and Core Competencies

• Provide advanced complex medical records reviews and code all relevant diagnoses, including chronic conditions, using ICD‑10 coding guidelines for Commercial and Medicare risk adjustment programs.
• Conduct thorough clinical documentation review to ensure sufficient support for coded conditions.
• Identify opportunities to improve documentation and coding accuracy; provide analysis and recommendations for improvement to leadership.
• Consistently meet productivity and quality standards as outlined by supervisor.
• Ensure coding compliance by following Official Coding Guidelines, HHS‑RADV Protocols, and attending REGTAP calls.
• Stay current with coding standards, risk adjustment methodologies, and CMS regulatory changes to ensure ongoing compliance and optimal coding practices.
• Actively contribute to achievement of departmental goals as identified in the department’s annual business plan, including specific departmental process improvement plans, and other duties as assigned.

Qualifications

Education/Specialized Training/Licensure: Bachelor’s Degree or five or more years of experience in risk adjustment in lieu of a degree in a managed care organization required. AHIMA/AAPC Certified Coder with a Medical Billing and Coding certification (CPC, CRC, COC, CCS, CCS‑P, or any combination) required. Associate or bachelor’s degree preferred.

Work Experience (Years and Area): Three to five years’ experience in Commercial or Medicare risk adjustment coding required.

Clinical Documentation Improvement Experience for Inpatient and Outpatient: Preferred. Experience within a managed care organization preferred.

Some Management Experience: Preferred.

Software Proficiencies: Microsoft 365 (Word, Excel, Outlook, SharePoint, Teams).

Other: Strong analytical skills; strong written and verbal skills; strong interpersonal skills; solid knowledge of ACA, Medicaid, and Medicare risk adjustment.