Risk Adjustment Quality Specialist

100 Lawrence Memorial Hospital; City of Rochester (NY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Professional development

Excellent benefits

Job summary

100 Lawrence Memorial Hospital is seeking a Risk Adjustment Quality Specialist to coordinate and support prospective, concurrent, and retrospective reviews to assist with patient care management and to translate, input, extract, and validate medical record data related to HCC coding.

The role includes education, audits, collaboration with medical staff, monitoring quality program performance, and staying compliant with CMS rules; hybrid work with on-site meetings in specified states.

Qualifications

• Minimum 3 years of medical coding or risk adjustment experience focusing on HCCs and value-based care.
• Strong knowledge of CMS risk-adjustment and quality initiatives.
• Completion of an AHIMA certificate or AAPC credential.
• Preferred RN Associate or Bachelor’s in Health Information Management.
• Experience with 3M Coding Solution.
• Hybrid work - must reside in Kansas or Missouri and attend on-site meetings.

Responsibilities

• Perform comprehensive reviews of patient records to assess documentation and determine coding with CMS HCCs.
• Monitor revenue opportunities related to value-based care.
• Manage provider query process to clarify documentation and ensure accuracy of diagnoses.
• Provide education to providers to improve documentation and coding accuracy.
• Analyze performance data to identify trends and opportunities for improvement.
• Collaborate with medical staff to support accurate coding and reimbursement.
• Participate in audits and continuous-improvement initiatives.

Skills

Medical coding

Risk adjustment

Data analysis

CMS guidelines

Audits

Education

AHIMA credential

RN or HIM degree

Tools

3M Coding Solution

Job description

Job Summary

The Risk Adjustment Quality Specialist coordinates and supports prospective, concurrent, and retrospective reviews to assist with patient care management. The role provides education and facilitates chart retrieval for Health Plan audits and reports. It requires a comprehensive understanding of Hierarchical Condition Categories (HCC) coding to accurately translate, input, extract, and validate medical record data. The specialist assists with monitoring quality program performance, including tracking, reporting, and implementation of best practices and program requirements.

Essential Job Responsibilities

• Perform comprehensive reviews of patient medical records to assess documentation consistency and adequacy, identifying appropriate coding based on CMS HCC categories.
• Monitor revenue opportunities related to value‑based care.
• Manage the provider query process to clarify documentation and ensure completeness and accuracy of patient diagnoses, especially for chronic conditions.
• Use evidence‑based practices to provide providers with targeted feedback and education on improving documentation and coding accuracy related to HCC.
• Demonstrate analytical and problem‑solving ability to address barriers in receiving and validating accurate HCC information.
• Analyze performance data to identify trends, gaps, and opportunities for improvement.
• Maintain an intermediate to advanced understanding of claims processing procedures, state and federal regulations, and Medicare Part D requirements.
• Utilize coding software to ensure compliance with Medicare, Medicaid, and other payer requirements.
• Collaborate with medical staff to clarify documentation and support accurate coding and reimbursement.
• Participate in audits, quality reviews and continuous‑improvement initiatives.
• Educate staff on coding practices and HCC assignments.
• Maintain compliance with policies, procedures, and continuing‑education requirements.
• Perform additional duties as needed or assigned.

Job Qualifications

• Minimum 3 years of experience in medical coding or risk adjustment with a focus on Hierarchical Condition Categories, value‑based care contracts, and accountable care organizations.
• Strong knowledge of CMS risk‑adjustment and quality initiatives, including HCCs.
• Completion of an AHIMA accredited certificate program (e.g., Certificate Coding Associate, Certificate Coding Specialist, Certified Professional Coder, Registered Health Information Technician, Registered Health Information Administrator) or credential from AAPC.
• Preferred: Registered Nurse Associate or Bachelor’s Degree in Health Information Management.
• Experience with 3M Coding Solution knowledge.
• Hybrid work flexibility: must reside in Kansas or Missouri and attend on‑site meetings as scheduled.

Benefits

• Competitive pay and advancement potential.
• Tuition reimbursement to support continuing education.
• Professional development and recognition.
• Excellent benefits package.

We are an equal‑opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.