Risk Adjustment Quality Specialist

LMH Health; United States; On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

LMH Health is seeking a Risk Adjustment Quality Specialist to coordinate and support reviews, education, and chart retrieval for health plan audits. You will translate, input, extract, and validate medical record data using HCC guidelines.

The role supports monitoring quality program performance and works with providers to improve documentation and coding accuracy, with a focus on risk adjustment initiatives.

Qualifications

• Minimum 3 years of experience in medical coding or risk adjustment focusing on HCC and value-based care.
• Strong knowledge of CMS risk adjustment and quality initiatives including HCCs.
• Completion of AHIMA or AAPC credential listed or equivalent.
• Credentialed through AAPC acceptable.

Responsibilities

• Perform comprehensive reviews of patient records to identify coding based on CMS HCC categories.
• Monitor revenue opportunities related to value-based care.
• Manage provider query process to clarify documentation and ensure accuracy of diagnoses.
• Provide education to providers on improving documentation and coding accuracy, specifically HCC.
• Analyze performance data to identify trends and opportunities for improvement.
• Maintain understanding of claims processing, regulations, and Medicare Part D requirements.
• Utilize coding software to ensure compliance with payer requirements.
• Collaborate with medical staff to support accurate coding and reimbursement.
• Participate in audits, quality reviews, and continuous improvement initiatives.

Skills

Medical coding

HCC knowledge

CMS risk adjustment

Audits

Data analysis

Staff education

Communication

Education

AHIMA coding credential

AAPC credential

Health Information Management degree

Tools

3M Coding Solutions

Coding software

Job description

Something special starts here.

You can’t define it, but you know it when you see it: the difference between an average life and the good life. When your cup is full – with joy, purpose and lifelong health – it shows. At LMH Health, we are all about healthy people, healthy communities and healthy futures, and that makes us your destination for an exceptional career. From flexible, work-life harmony to competitive pay and great advancement potential, find everything you’re looking for at LMH Health.

You’ll find everything you’re looking for at LMH Health:

• Join a team that cares about the community
• Tuition reimbursement to support continuing education
• Professional development and recognition
• Excellent benefits

We’re looking for you.

Job Description

I. JOB SUMMARY

The Risk Adjustment Quality Specialist plays a vital role in coordinating and supporting prospective, concurrent, and retrospective reviews to assist with patient care management. The position provides education and facilitates chart retrieval for Health Plan audits and reports. This position requires a comprehensive understanding of Hierarchical Condition Categories (HCC) coding to accurately translate, input, extract, and validate medical record data.

This role assists with monitoring quality program performance, including tracking, reporting, and implementation of best practices and program requirements.

II. ESSENTIAL JOB RESPONSIBILITIES

• Perform comprehensive reviews of patient medical records for documentation consistency and adequacy to identify all appropriate coding based on Centers for Medicare & Medicaid Services (CMS) HCC categories.
• Monitor revenue opportunities related to value-based care.
• Manage the provider query process to clarify documentation and ensure the completeness and accuracy of patient diagnoses, particularly related to chronic conditions.
• Utilize evidence based practices to provide providers with targeted feedback and education on improving documentation and coding accuracy, specifically related to HCC.
• Demonstrate analytical and problem-solving ability with regard to barriers in receiving and validating accurate HCC information.
• Analyze performance data to identify trends, gaps, and opportunities for improvement.
• Maintains 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.
• Performs other duties as needed or assigned.

III. JOB QUALIFICATIONS

Required :

• Minimum of 3 years of experience in medical coding or risk adjustment with a focus on Hierarchical Care Conditions, value based care contracts, and accountable care organizations.
• Strong knowledge of CMS risk adjustment and quality initiatives, including Hierarchical Condition Categories (HCCs).
• Completion of one of the following through AHIMA accredited programs: Certificate Coding Associate, Certificate Coding Specialist, Certified Professional Coder, Registered Health Information Technician, Registered Health Information Administrator
  OR
• Credentialed through AAPC

Preferred :

• Registered Nurse
• Associates or Bachelor’s Degree in Health Information Management
• 3M Coding Solution Knowledge

Remote Work/Work-from-Home :

This position has hybrid work flexibility. This person must live within Kansas or Missouri, and will be required attend on-site meetings, as scheduled.

Our Cultural Beliefs

• People First
• Integrity Matters
• Better Together

At LMH Health,we value inclusion and diversity. 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.