Risk Adjustment Coding & Compliance Expert

Blue Shield of California; California (MO); Hybrid; USD 123,000 - 185,000; Full time

Job summary

Blue Shield of California seeks a Risk Adjustment Compliance Coding Specialist (Consultant) to ensure accurate coding for ACA, Medi-Cal, and Medicare Advantage programs. You will review clinical documentation, assign ICD-10-CM codes including HCCs, and support audits to maintain regulatory compliance and proper reimbursement.

The role requires a bachelor’s degree and CRC/CPC/CCS or equivalent, 6+ years in healthcare coding/compliance, proficiency with EHR systems and CMS guidelines, and

Qualifications

• Requires a bachelor’s degree or equivalent experience in Health Information Management, Nursing, Health Administration, or related clinical field.
• Deep familiarity with ICD-10-CM coding, risk adjustment models (CMS-HCC, HHS-HCC), and regulatory requirements.
• Excellent analytical, communication, and documentation skills.

Responsibilities

• Examine patient records to identify diagnoses affecting risk adjustment scoring.
• Assign ICD-10-CM codes including HCC based on clinical evidence and CMS/HHS guidelines.
• Conduct quality audits, develop workplans, and address discrepancies.
• Collaborate with physicians and clinical staff to clarify documentation and improve coding accuracy.
• Monitor regulatory updates and risk adjustment policies to maintain compliance.

Education

Bachelor's degree (Health Information Management / related field)

Job description

Blue Shield of California seeks a Risk Adjustment Compliance Coding Specialist (Consultant) to ensure accurate coding for ACA, Medi-Cal, and Medicare Advantage programs. You will review clinical documentation, assign ICD-10-CM codes including HCCs, and support audits to maintain regulatory compliance and proper reimbursement.

The role requires a bachelor’s degree and CRC/CPC/CCS or equivalent, 6+ years in healthcare coding/compliance, proficiency with EHR systems and CMS guidelines, and